Restructuring of Mental Health Services: HSE

I welcome to the meeting from the Health Service Executive, HSE, Mr. Dean Sullivan, deputy director general, strategy; Ms Anne O'Connor, chief operations officer; Mr. Pat Healy, national director of community strategy and planning; and Mr. Jim Ryan, head of operations, mental health. On behalf of the committee, I thank the witnesses for their attendance today. The format of the meeting is that they will be invited to make a brief opening statement, which will be followed by a question-and-answer session.

Before we begin, I draw the attention of witnesses to the situation on privilege. Witnesses are protected by absolute privilege in respect of the evidence they give to the committee. However, if witnesses are directed by the committee to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable.

Members should be aware that under the salient rulings of the Chair, they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

I remind members and witnesses to switch their mobile phones to aeroplane mode as they interfere with the sound system. I also wish to advise the witnesses that any submission or opening statement they have made to the committee will be published on the committee website after this meeting. I invite Mr. Dean Sullivan to make his opening statement.

Mr. Dean Sullivan

I am deputy director general in charge of strategy and planning for the HSE. I am very grateful for the invitation to attend this meeting of the Committee on the Future of Mental Health Care. I am joined today by three colleagues. Mr. Pat Healy is national director for community strategy and planning. To my left is Ms Anne O’Connor, national director for community operations, and to Ms O'Connor's left is Mr. Jim Ryan, who is head of operations within mental health.

I am very pleased to appear before the committee today to speak to members about the future of mental healthcare and, more specifically, the structures that have changed within the HSE in recent months. I will begin by giving an overview of those changes that have taken place since 1 January.

We have a reform programme within the HSE, which is focused on how we work and the structures we work within. As part of building a better health service, the HSE is implementing changes to the way in which we are organised, particularly in the context of the appointments last summer of John Connaghan as chief operating officer and of me as chief strategy and planning officer. More recently, in April 2018, Dr. Colm Henry took up the role of interim chief clinical officer and we, as three senior managers within the HSE, are now working in a triumvirate manner in line with the new ways of working we are seeking to take forward as an organisation.

With effect from the beginning of January, the roles of a number of existing HSE national directors have changed to facilitate the separation of those activities relating primarily to strategy and planning from those relating primarily to operations and delivery. In this regard, Anne O’Connor is now responsible for the delivery side of the house in terms of her role as community operations and Pat Healy is responsible for community strategy and planning. Dr. Philip Dodd remains in his role as national clinical lead for mental health services.

These and other changes have been signalled for some time in the context of the journey to transform the way in which we deliver services in order to build a better health service and strengthen governance and accountability arrangements. This is fully in line with Government policy and the recommendations of the Sláintecare report, which refers clearly to the need for the HSE to be re-orientated to a more strategic, leaner national centre.

Since the establishment of the mental health division in 2013, there have been tangible service improvements for patients and clients with an increase in the percentage of funding going towards mental health from the overall health budget. Since 2013, mental health expenditure has increased by 22% from €709 million to €867 million. I assure members that all funding allocated to mental health by Government is being spent on mental health services.

In recent years, there has been an increased recognition of the need for an integrated approach to the design and delivery of health services to people with mental illness and other co-morbid illnesses. The organisational changes now being implemented within the HSE are designed to build on successes to date through a separate, though integrated, approach to strategic planning, operational oversight and the delivery of mental health services. Having developed a strong delivery system through the introduction of community healthcare organisations and hospital groups, it is important that the role of the centre within the HSE changes to one which supports and enables the delivery of services as opposed to actually being involved in the day-to-day delivery of those services.

In her role as head of community operations, Anne O’Connor is supported by a dedicated operational lead for mental health who is with us today, Jim Ryan, working closely with a dedicated planner for mental health, John Meehan, from community services strategy and planning, that is, on Pat Healy's side of things. In addition, these specialists and their teams will work alongside a number of other teams and networks with a focus on integration. The establishment of the chief clinical officer role within the HSE also brings an additional clinical focus on mental health, working closely with both my side of the house on strategy and John Conaghan's side of the house on operations.

Mental health services in Ireland are integrated with primary care, acute hospitals, services for older people, services for people with disabilities and a wide range of community partners. Services are provided in a number of different settings including health centres, day hospitals, inpatient units and sometimes in the user’s own home. Over 90% of mental health needs can be successfully treated within a primary care setting, with less than 10% being required to be referred to a specialist community based mental health team. Of this number, approximately 1% are offered inpatient care, with nine out of ten of those admissions being voluntary.

Regionally, the nine community healthcare organisations, CHOs, have responsibility for the delivery of community healthcare services within their respective geographical patches. While the chief officer of the CHO has overall responsibility within each organisation, the head of service for mental health, in conjunction with the executive clinical director, is responsible for the delivery of mental health services across the respective CHO areas.

As members will be aware, forensic mental health services operate on a national basis.

These organisational changes are intended to achieve the following benefits: an appropriate organisational focus within the HSE centre on strategy and planning and oversight of operational delivery; strong and visible clinical leadership at the most senior level; robust planning arrangements including assessment of needs, inequalities, outcomes and access to services; a more structured approach to the identification of issues with a clear focus on the development and implementation of plans for improvement informed by service user experience and best practice; effective integration of services at national, regional and local levels; and robust performance management and service improvement arrangements across the system.

In relation to service users, the organisation changes are intended to achieve improved access to services, improved flow through services from mental health to primary care or to acute hospitals and returning to the community and more consistent support to service users to ensure they receive the right service, at the right time, in the right place, by the right team.

To conclude, I highlight the point that complex system-wide change, such as the type that I have outlined, will take time to complete and it is vital that we maintain stability during the transition phase. Notwithstanding the changes under way, there is a firm commitment within the HSE to the ongoing delivery and development of mental health services for all age groups.

I look forward to answering any questions the committee may have.

The committee is aware that this structure was already in place and is not new and that similar structures to the one outlined were in place prior to 2017.

Mr. Dean Sullivan

May I clarify something?

If Mr. Sullivan does not mind, we will hear from the committee first. The format for today's meeting is that members are allocated seven minutes, during which questions are asked and we ask that Mr. Sullivan answers as quickly as possible in order that we get in as many questions as possible.

I thank Mr. Sullivan for his attendance and presentation. With the greatest respect, I think I speak for many members when I express my disappointment and frustration. I understand that Mr. Sullivan was invited to this committee on 17 April and we received a submission yesterday, less than 24 hours before the meeting. Before my election to the Oireachtas, I ran a student council with second level students and they knew that the agenda and submissions to the meeting came in a week earlier, and they were children aged 12 to 18 years. That is deeply frustrating. I was watching out for the submission over the last five days as I wanted to study it and I do not think the three-page document that we received is good enough. Within the three pages, as Deputy Rabbitte has noted, there is nothing into which one can sink one's teeth. There are phrases such as "maintain stability during the transition" and it tells us that over 90% of mental health needs can be successfully treated in primary care, when from previous meetings we know that we only have 37 general practitioners in Kilkenny, 41 in Kildare, 38 and Longford and there is a crisis in this area. I do not think that it is acceptable.

Given previous evidence that dedicated resources are needed within mental health to drive forward policy, will Mr. Sullivan explain why the decision has been taken to remove the national director for mental health?

In his submission, Mr. Sullivan pointed to an increase of 22% in mental health expenditure since 2013. That read to me like the kind of answer the Minister would give to me in response to a parliamentary question or something I would see in a Government party manifesto. Where is that money going? Over the course of this committee's work, we have heard of the huge numbers of staffing positions being unfilled, how people remain on practically indefinite waiting lists and it was reported yesterday that in just one month, there was a 10% increase of young people waiting for services for over a year. If there has been an increase in funding over five years, I would like to know where it is going and, more importantly, the reason it is not being felt by service users.

Mr. Sullivan stated there have been tangible results from the increased spending. What are they? Who will have the authority to set priorities for the mental health expenditure across the country?

How will the structural changes address the issues in recruitment, retention and pay as well as the lack of resources and poor working conditions? It is no good saying that we have increased spending and changed HSE structures when we do not have the front-line staff to provide care. Who in the HSE will provide the dedicated leadership on delivering and improving mental health services?

Mr. Sullivan stated that the "changes now being implemented within the HSE are designed to build on successes to date". Will he list some of those successes? We have 2,500 children waiting for a first mental health appointment. The child and adolescent mental health services, CAMHS, continue to operate at just 50% of recommended staffing levels. A recent report found that some third level institutions have indicated a 41% increase in students seeking counselling over the past three years. There is now a six-month waiting list for counselling services in many institutions. When he speaks of successes to date, Mr. Sullivan will find many service users are not experiencing successes.

Last year, the Sláintecare report recommended that 10% of the overall health budget be spent on mental health, the 12 year old A Vision for Change document recommended 8.24%, yet currently we are at 6%. Is 10% achievable? When can we reach 10%. Should we aim higher? What will the HSE do to secure this budgetary allocation? Whose responsibility is it to get us up to best practice standards of 10%?

I think that the Deputy has thrown out a few questions. I will ask the witnesses to try to answer some of them.

Mr. Dean Sullivan

I will start and colleagues will come in. I apologise if the statement was not as comprehensive as the Deputy had hoped. It is only the second such committee which I have personally attended. We were told we had a certain number of minutes and in her introductory remarks, the Chair herself asked us to keep our contribution brief. If after the meeting more information is required, I will be happy to forward it on if it is helpful.

The Deputy asked why the decision was made to restructure. I will rehearse what the restructuring looks like, and I might have a chance later to revisit the question of its timing. The organisation has restructured at the highest level in having clinical, operations delivery and strategy and planning arms. It is commonly reported and felt by staff in the organisation that one of our challenges is too great a focus on day-to-day delivery of services and firefighting and not enough focus on medium and long-term planning, prioritisation, needs assessment, identification of inequalities and so on. Notwithstanding that John Meehan and I came into posts last summer, which was the beginning of the new arrangements, the structural changes that have been put in place at the start of this year with Ms O'Connor and Mr. Healy moving into their respective roles was entirely consistent with that. It is to retain absolutely priority in the needs of mental health service users and making sure that we respond to those needs, as well as the needs of other users, but to recognise that that is a very broad agenda and that it might be helpful, certainly as we transition towards an arrangement where greater power is devolved to the provider organisations, to have a clear focus on the strategy and planning side of things and a clear focus on the delivery side of things. That is-----

I am sorry for cutting in, but Deputy Catherine Martin wants to contribute.

It was my understanding when A Vision for Change was launched, that it recommended the establishment of a directorate for mental health. In 2008 a report of the Inspector of Mental Health Services voiced strong concern about the lack of a separate mental health services directorate. Does that mean that some evidence has been gathered that we do not need it because it was welcomed when it was established? What is the rationale for taking it away?

Mr. Dean Sullivan

I do not think I will get the chance to talk about this during the course of the afternoon. On the committee's interim report which was mentioned by the Chairman, mental health services are not delivered in a bubble. There is huge reliance on primary care services in meeting the bulk of needs of mental health patients. When we ran services up and down, it became difficult to plan for the silos being run to actually work out the opportunities to provide more seamless care for patients. We now have a structure in place that allows for that path in the oversight of all community services, everything from primary care services through to mental health and older persons' and disability services on the planning and strategy side of things. Ms O'Connor has responsibility in working with Mr. Ryan and others for making sure services are delivered. As I mentioned, Dr. Philip Dodd is solely involved on the mental health service line, given his particular professional background. We have and will continue to have a very clear focus on mental health services, but we will have a really clear focus on understanding the needs of patients and making sure we put in place appropriate evidence-based services to respond to their needs. That was more difficult to do in the past.

The HSE did not understand the needs of patients, but it will now have a better understanding because of this structure.

Mr. Dean Sullivan

In the past it was sometimes difficult for any silo in having responsibility for both planning and delivery to understand the needs of patients as thoroughly as we are able to do now. Crucially, in the past it was more difficult to plan how best to respond to needs in the delivery of integrated services across all spectrums within primary and community care services.

Is there an intention to review the structure within a year to see whether it is working and improving?

Mr. Dean Sullivan

That is an entirely reasonable point to make. Any big change like this needs to be reviewed on an ongoing basis because there will be challenges, lumps and bumps. There will be challenges, lumps and bumps in considering how effective the structure is, what it feels like for individuals and how it is working in practice. It will evolve over time.

Will the findings of any such review be published?

Mr. Dean Sullivan

I do not think it is the intention to do anything as formal as that, but I am happy to go away and have a think about whether something like that might be helpful. We will certainly keep the position under review.

Can Mr. Sullivan tell me about the organisational structure?

Mr. Dean Sullivan

It is probably easier for me to describe it in the context of the position of the director general having changed last week and so on. We will leave names out until we get to the four of us. There is a director general at the top of the organisation. In the context of this discussion, there are three key reports on the director general, excluding matters such as HR and finance. There are three key feeds-in. One is the feed I lead - the strategy and planning team. The second is the operations and delivery team, while the third is the chief clinical officer's team. There is one person at the top, to whom the three teams report, excluding on matters such as HR and finance. Mr. Healy is one of three directors who work with me. Within the operations and delivery team, Ms O'Connor is one of three directors.

Therefore, Mr. Sullivan covers planning and strategy?

Mr. Dean Sullivan

I do.

Ms O'Connor covers delivery of the strategy.

Mr. Dean Sullivan

That is exactly right.

Mr. Healy covers the clinical side. Is that correct?

Mr. Dean Sullivan

No, I cover the strategy and planning side. I have someone - Mr. Healy - who leads on the community side in planning, including mental health services. On my side of the house I have someone who leads on the acute services side and someone who leads in devising longer term strategies and responding to Sláintecare.

Mr. Sullivan's silo is planning and strategy.

Mr. Dean Sullivan

My area of responsibility covers planning and strategy.

Does it actually involve the delivery of the strategy?

Mr. Dean Sullivan

That is exactly right.

I will write this down. If that is Mr. Sullivan's silo, how does it interlink with the operations and delivery team? What is the difference between-----

Mr. Dean Sullivan

Is the Deputy referring to CHOs, hospital groups and so on?

Do CHOs and hospital groups come within the area of the operations and delivery team?

Mr. Dean Sullivan

Yes, they do. Ms O'Connor can explain how she interfaces with CHOs on a regular basis.

If Mr. Sullivan gives me one second, I am trying to understand it. He plans the strategies for the next two, four, five or six years. How will he interact with the likes of Sláintecare? Is he implementing it? From where do his goals come?

Mr. Dean Sullivan

No, it also sits with me. Clearly, when the Government's implementation plan for Sláintecare is published in the near future, it will become a key driver of our focus as an organisation, but yes, it sits with me. There is a risk in these conversations that I could sound jargonistic when I do not mean to.

Mr. Dean Sullivan

It is as straightforward as the Deputy described it.

Therefore, Ms O'Connor's role is as a conduit between the planning and strategy team and the CHOs?

Mr. Dean Sullivan

Precisely.

There is obviously a conduit that links with the clinical side also.

Mr. Dean Sullivan

There is a conduit that links with the hospital side also. Ms O'Connor's equivalent number is Mr. Liam Woods. Those on the clinical side support both of us. Moving from the silos-----

What is the difference between a hospital group and a CHO?

Mr. Dean Sullivan

A hospital group is a group of hospitals which are delivering hospital services. CHOs are community and primary care organisations.

Does a hospital group sit under the operations and delivery team?

Mr. Dean Sullivan

Yes. Community health organisations are on Ms O'Connor's side of the house, while the hospital groups are on Mr. Liam Woods's side of the house.

How does the clinical side interlink with them?

Mr. Dean Sullivan

If I had a piece of paper, I would draw it for the Deputy.

I actually asked for a breakdown.

Mr. Dean Sullivan

Mr. Healy will give it to the Deputy. If one can imagine three arms coming from the director general, one is strategy and planning, one is operations and the other is clinical. The clinical arm supports both of the others. What the guys and I cannot have is one clinical opinion on mental health services on whether it was on the operations side of the house. We are getting a different opinion with regard to strategy and planning. Therefore, it is one spine down the middle of the organisation.

How does each operation arrive at its budget? Mr. Sullivan said finance and HR were shared services across the three pillars.

Mr. Dean Sullivan

Yes, that is right.

How does Mr. Sullivan arrive at his budget to be able to go back to HR or finance and say he wants X, Y and Z for recruitment or whatever else?

Mr. Dean Sullivan

The Deputy is taking us into the space of the annual planning cycle, whereby mental health services would make a bid, disability services would make a bid and acute services would make a bid, all of which would go through the Estimates process.

How did they arrive at making a bid?

Mr. Dean Sullivan

Through a combination of their own insights and understanding of material risks, capacity, gaps, opportunities, transformations and changes that need to be made.

Mr. Sullivan used the word "bid". Are they making an estimation or do they-----

Mr. Dean Sullivan

No. As the Deputy probably knows better than I do nine months into this job, there is an Estimates process that involves a discussion between the Department of Health, the Department of Public Expenditure and Reform and in due course the Government and us from which will arise a health budget, among other things.

Let us take as an example CAMHS. It will come under the operations and delivery team. Is that correct?

Mr. Dean Sullivan

That is right. The delivery of CAMHS comes under it.

Is the budget for CAMHS dictated across all three pillars?

Mr. Dean Sullivan

No, its budget will be determined in the planning and strategy process. It will be X million euro. Ms O'Connor will be tasked with making sure services are delivered.

Therefore, the budget of CAMHS will be dictated by Mr. Sullivan's pillar?

Mr. Dean Sullivan

Correct.

How does he arrive at the figure for the budget for CAMHS?

Mr. Dean Sullivan

That takes us back to the very highest level. There are significant resource pressures within health and social care services, including mental health and other services that have been well documented.

I am asking Mr. Sullivan for the figure for child and adolescent mental health services, CAMHS.

Mr. Dean Sullivan

I will come around to that.

It is a straight question.

Mr. Dean Sullivan

I will get to it. I just need to provide context. The budget for health and social care is light at a macro level in Ireland anyway, so in a context in which there are insufficient resources to do all the things we would wish to do, our challenge is to decide how to prioritise the scarce existing resources, and the even scarcer new resources we can secure, towards the areas of greatest need. The top of the shop in that will be cases of material, live risks to the quality of patient safety. These are areas in which there is a need to bolster staff. Not far behind that would be areas in which there is a material capacity gap within a particular service.

I will rephrase my question in order to get some clarity. The HSE has a figure for CAMHS every year.

Mr. Dean Sullivan

We do.

That figure is delivered to the top and to those responsible for finance. Mr. Sullivan says that he needs X, Y and Z for CAMHS. We are putting down parliamentary questions every day of the week seeking a figure for what is spent on CAMHS every year.

Mr. Dean Sullivan

That is right.

I have been told that I will not and cannot be given that figure because of the way the systems are set up. Mr. Sullivan has just told me today that he goes back to those responsible for finance and gets a figure for CAMHS under his remit.

Mr. Dean Sullivan

No, I get a wider figure for mental health expenditure.

Mr. Sullivan told me he could give me a figure for CAMHS.

Mr. Dean Sullivan

I may have used clumsy language. I apologise. I can get a figure for mental health expenditure.

Mr. Sullivan cannot get a figure for CAMHS however.

Mr. Dean Sullivan

We have challenges within our financial systems about which I believe Ms O'Connor has already spoken to the Deputy. Other colleagues have already spoken to the Deputy about them previously. We have challenges within our financial systems which make it more problematic. We talked about strategy and planning. I do know how many patients will require a CAMHS intervention, the capacity we have to respond to that-----

Mr. Sullivan is repeating himself quite a bit and I think Deputy Neville wants to-----

I only have seven minutes. How many minutes do I have left?

The Deputy has about a minute.

I have a minute left. I am sorry about this but I am under a time constraint.

Mr. Dean Sullivan

That is fine.

The last question I have is in respect of the moneys that are spent. In 2016 there was €35 million of new money. A certain amount of money was spent on new expenditure and a certain amount was spent on improving existing services. I was told the last time that the decision on the moneys that would be spent on improving existing services was a collective decision, taken in conjunction with the Minister. What position signs off on that final figure?

Mr. Dean Sullivan

Which final figure?

The figure allocated to the improvement of existing services. What position signs off on that final figure?

Ms Anne O'Connor

We have development funding every year so in terms of the additional funding we get-----

The HSE got €35 million in 2016. Some of it was spent on new services and some was spent on the development or improvement of existing services. Who signs off on the final figure for what is spent on improving existing services? What position signs off on that?

Ms Anne O'Connor

It is agreed with the Department of Health.

What position signs off on it? Who has the final sign-off? Who signs the dotted line to say this goes ahead? Is it the Minister or someone from the HSE?

Ms Anne O'Connor

I am not sure that it is a position. We get the funding. We do a proposal for how that funding might be used based on what we know. We discuss it with the Department and the Minister and we either get the go-ahead or we do not.

From whom do the witnesses get the go-ahead?

Ms Anne O'Connor

From the Department. The internal workings of the Department are-----

The final sign-off comes from somebody in the Department.

Ms Anne O'Connor

In terms of the new development funding and what it is used for, yes.

That refers to the €35 million. I am talking about the continuation or improvement of existing services. The last day the witnesses were here in front of me they could give me a figure of how much was spent as new money and how much was spent on improving existing services. I use the term "plugging gaps" while the witnesses use the term "improvement of existing services". I cannot be given that figure so I want to know who signs off on the improvement of existing services. Who makes the final decision?

Ms Anne O'Connor

We seek to improve services all the time with our core budget as well as any additional funding.

Is Ms O'Connor telling me that nobody makes the final decision? Is it a collective decision? Where is the accountability in the making of that decision?

Ms Anne O'Connor

The budget allocated to each community healthcare organisation, CHO, is agreed with a chief officer such as myself in the case of the core budget. If it has to do with development funding, the programme of work is agreed with the Department. That is usually a phased development of different new initiatives.

I am talking about the improvement of existing services.

Ms Anne O'Connor

We agree that internally. I agree priorities with the chief officers and with the team around me.

That is the case for each CHO.

Ms Anne O'Connor

Yes, that is the case for the funding of each CHO but we do not have a budget line for improvement. For example, if there was a development in CAMHS, the CHO might get a couple of extra posts through new development funding, it might get a new team or it might get funding for some other initiatives.

That is new services, not the existing services.

Ms Anne O'Connor

The provision of services has to continue so the core budget comes into that. The core budget we get in 2018 will have to be used to continue the services which were there in 2017. We also have other initiatives, for example, quality and patient safety initiatives, which are aimed at improving services, making them safer and looking at how we involve service users.

I am just trying to ascertain how much of the €35 million in 2016 went into new service and how much went into the continuation of existing services.

Ms Anne O'Connor

Is the Deputy asking how much goes into plugging the holes in the existing level of services, for example, the overruns on agency staff and so on?

No. I will rephrase it again. It is pretty simple. Some €35 million was given in 2016. That was for the development of new services. We were told that all of it could not be spent and that some of it went into the continuation or improvement of existing services. I just want to know how much was put into the continuation or improvement of existing services. That is all.

Ms Anne O'Connor

I do not have that figure but I can look for it.

I asked for that figure six months ago and I still have not got it. I asked the witnesses for it the last time they were in here.

We will send an official request to Ms O'Connor for that figure. Before I pass Mr. Sullivan on to Deputy Rabbitte, he was trying to describe the flow chart. I am not asking him to do that. It would be far easier for all of us if he could provide a diagram which would also include the number of people working in each department or section.

Mr. Dean Sullivan

I will happily furnish that.

I thank the witnesses for their presentation. I am going to question Mr. Sullivan in respect of a line on page 2 of the HSE's written submission. It states, "This is in line with government policy and aligns with the recommendations of the recent Oireachtas Report, Sláintecare, which refers to the need for the HSE to be re-oriented to a more strategic leaner ‘national centre’." Who decided on the restructure? Who signed off on it?

Mr. Dean Sullivan

As I understand it, though it pre-dates my appointment, the restructuring and the concept of moving toward a separation of strategy and planning and operations, but with an integrated way of working, was the result of a discussion between the Department of Health and the HSE. There may well have been other parties involved but my understanding is that it was a discussion at the highest level.

Is Mr. Sullivan saying that the Minister, Deputy Simon Harris, signed off on the restructuring?

Mr. Dean Sullivan

I do not know whether the Minister would have been involved but the discussion around the creation of the two deputy director general roles and of the chief clinical officer role was certainly a discussion between the Department and the HSE.

So was it the director general?

Mr. Dean Sullivan

Again I do not know because it pre-dated my appointment but I imagine the Department of Public Expenditure and Reform would also have been involved. My understanding is that it would have had to sanction the roles being created.

Perhaps Mr. Healy could answer that for me.

Mr. Pat Healy

That would have been the case at the time. There would have been a discussion between the HSE and the Department. Obviously all posts of that nature would require approval from the Department of Public Expenditure and Reform. My understanding is that there was that two-way discussion and then approval from the Department of Public Expenditure and Reform.

Mr. Dean Sullivan

The translation of that high-level principal change in the creation of the three posts into a structure beneath it is the work which I have been describing. That has been evolving in recent months.

That brings me to my next question. I appreciate that Mr. Sullivan is new in the role. The discussion and everything else were had but then the direction had to come. Where did the direction come from?

Mr. Dean Sullivan

To what direction is the Deputy referring?

The direction for the restructuring. The direction had to come from somebody. Somebody had to sign the piece of paper and say that the HSE is changing how it does business.

Mr. Dean Sullivan

I do not think a direction was required in that context insofar as once there was approval for the posts, there was no need of which I am aware - though colleagues may wish to comment - for any additional direction or authorisation in order to proceed. The agreement was secured for a move towards a structure within the HSE centre which focused more on strategy and planning as distinct from operations and delivery and which had a separate, very clear clinical officer spine such as I have spoken about. Once that agreement had been reached and the authorisation secured for the three posts - although it did not result in any additional posts it still required authorisation - my understanding is that the HSE was then just allowed to make the necessary arrangements.

So it was the HSE. That would have been signed off by Tony O'Brien at the time.

Mr. Dean Sullivan

Yes.

That is okay. I just wanted to find out exactly where that decision was made.

That brings me to my next question, and Deputy Neville has covered much of it. Will there be a dedicated national mental health budget, separate from the HSE general budget?

Mr. Dean Sullivan

It is an interesting question. We are very clear about the mental health needs of patients. Those mental health needs, as the committee's interim report mentions, are met in a range of settings. It would be nearly impossible, and I am not sure how appropriate it would be, to try to ring-fence mental health patients distinct from all other patients in that regard. If I am seeking, as I will be with my colleagues, to deliver mental health services in a more integrated way than is currently the case, for example, GPs deliver a number of mental health services to patients, the practicality of separating that bit that relates to mental health services from the overall primary care budget-----

Ms Anne O'Connor

If I can clarify, the specialist mental health service budget is what it is. What Mr. Sullivan is referring to is the many other services that provide services to people with mental health difficulties as well. We do not capture that as part of the specialist mental health service budget when somebody with a mental health difficulty goes to a GP or goes to an acute hospital. However, in terms of the core budget that exists for specialist mental health services, that remains intact as a dedicated budget.

Who is responsible for it?

Ms Anne O'Connor

It will come through me in terms of going to the chief officers for allocation every year.

The witness knows we had the chief officers before the committee.

Ms Anne O'Connor

Yes.

They provided us with 600 pages of paper on everything, right down to buying the tea bags. However, when it came to asking them questions on the day we found it very hard to get answers because people could not get through them. They told us that the reason so many pages were required is that the ICT system was not such that they could provide us with the information that was required to give a critical analytical approach on the questioning. Is that correct?

Ms Anne O'Connor

That is correct. The IT system does not do that. We have dealt with this previously when the chief financial officer was here. The systems we have are such that we can give the committee a breakdown of where every euro goes, down to the tea bags or whatever else the committee wishes to know, but it does not slice at another angle across the CAMHS. Within mental health a budget is assigned to an area. We have come from regional health boards, we now have community health organisations and there may be another change-----

How long is it since the change was made from community health boards to CHOs?

Ms Anne O'Connor

The CHOs have been in place for three years.

Usually, someone who sets up a new business and wishes to seek a loan would have to have financial trading accounts for 18 months. That is how it would be done. Those organisations are trading for 36 months so I should have three lots of accounts. Why do I not have something?

Mr. Pat Healy

What is essential to this throughout all the shifts, and I have been through them all from the health boards to the HSE to the regional directors, is that there has been a requirement to develop a new financial system. That system has now eventually been approved. It is in the process of being developed. When that is in place we will be able to give the Deputy the type of information she is seeking. When the CHOs were established, or the integrated service areas before that, that financial system had not been approved at that time. It has gone through all the approvals required with the Department of Public Expenditure and Reform and so forth. The CFO heads a programme board that is fully implementing the system. It will take a couple of years to implement it fully but the system will give the Deputy the type of information she is seeking in the future.

I have a final question for Ms O'Connor. What percentage of the overall health budget goes to mental health? What is it for 2015, 2016 and 2017? I am not looking for the breakdown.

Ms Anne O'Connor

It is 6.3%.

Will she explain the statement that since 2013 mental health expenditure has increased from €709 million to €867 million, an increase of 22%? I am trying to work that out.

Mr. Pat Healy

The rest of the health budget has increased at a higher rate. While the mental health budget has been increasing significantly, the budgets of other parts of the service, such as acute and so forth, have been increasing at a higher rate.

What was the mental health budget for 2017?

Mr. Pat Healy

It was €867 million.

What percentage was it of the overall budget?

Mr. Pat Healy

It was 6.3%.

What was it in 2016?

Ms Anne O'Connor

I do not have the figure here.

Mr. Dean Sullivan

We can provide a table that will show the figures for each year and what has changed over time if that would be helpful.

Ms Anne O'Connor

The overall health budget has grown and the percentage for mental health within that has changed. The target is to get to 10% but we have been around 6%.

It is nearly misleading when one sees 22%. In fact, the overall budget for mental health is 6%.

Ms Anne O'Connor

That is of the overall health budget, but the actual funding allocated to mental health has grown by 22%.

How is the HSE spending it?

Ms Anne O'Connor

We are spending it on all the services that are provided in the nine community health organisations.

Yes, but I am seeking the breakdown. I refer again to Deputy Neville's question, which was very succinct. Where is the difference in terms of improvement and development of existing services?

Ms Anne O'Connor

In recent years we have increased the number of teams, improved our infrastructure and developed clinical programmes looking at self-harm, early intervention psychosis and eating disorders. We have new eating disorders teams for adults and children. We are progressing dual diagnosis services. We have improved quality and safety by looking at all sorts of systems within our units and community teams. We have increased the compliance of our units in line with the Mental Health Commission requirements. We have looked at the involvement of service users and the employment of peer support workers in the services. Much money has gone on a range of things to do with service users and the development of a recovery ethos within our services, looking at how we use service users within services to inform the design and delivery of our services. There are a number of strands of improvement, and that is where the additional money has gone. The growth in funding from the development money that we have had in the last number of years has been primarily around the improvements related to clinical programmes, quality and patient safety, and service user involvement.

Where is it being spent in the community? By community I mean the people of east Galway, but it is replicated across the country. For example, there was a community house with six patients in Athleague. On the weekend of Storm Ophelia the patients were moved to Castlerea and elsewhere and the house has closed since then. The Rosalie unit is in the process of closing down. In Portumna the day hospital is considering changing its structure at present whereby a patient will get a visitation for half an hour once a week. That is why I want to know how the money is being spent in the community. It appears to me that we are doing a great deal of box ticking here, but where is the money going back into the community? That is what matters on the ground. It is not being felt. It is felt that the complete restructuring taking place at present is the weeding out of services in areas. I would like to have a breakdown of how money is being spent in the community.

While we might be putting in place many valuable services that are really needed, there are many dependent people in the community who need reassurances that their day hospital or day house will not close, because that is the message people in the community are getting. People have to travel for services where they might get a clinical support once a week. They have to come out of Ballinasloe to travel to Portumna. There were 28 people using the day hospital in Portumna. Now it appears they will have to go on an appointment system, the day house will close and they will have to attend a day hospital for a half-hour slot. That is not how these mental health patients operate. These people like to go into their day house, make a cup of tea, sit down and have the reassurance of talking to each other. We are trying to box people into a situation that they are not used to.

Ms Anne O'Connor

In terms of what we are trying to do, we have an underpinning framework based on recovery within the mental health services. It is about maintaining people in their lives in terms of employment and within their communities. Our intention is to support people. That is the reason we have initiatives such as the early intervention psychosis initiative and the independent placement and support, IPS, initiative, where we are supporting people to remain in employment in their lives so they are not attending day centres and so forth at all. That is really not the model we want-----

I will have to stop Ms O'Connor there. Deputy Rabbitte is also saying that the HSE can reel off all these so-called improvements but it is not being seen on the front line. I call Deputy Buckley.

I welcome the witnesses. I had a number of questions but we will have to reverse back to the start. I do not know if the witnesses are aware that a motion on the duty of candour was discussed in the Chamber last night. It was about accountability, responsibility and transparency in the system and particularly in the HSE.

Listening to Deputies Neville and Rabbitte and a number of other speakers, it is like - and I have said this before - emptying the Red Sea with a bucket with no ass on it. Every time we come in here to ask questions, we do not get answers. I will go right back to the start. If this is something new that is supposed to change, as we have heard the Chairman say already, it is something old that changed to something new and that is back to something old again.

I will go back to what we call a duty of candour: responsibility, accountability, where the buck stops and whose name is at the end of the docket. My questions are very simple, and I would like if the witnesses could give me names in response because this is very important and they are the persons to whom we need to talk. First, who appointed them? I do not want to hear the Department of A, B, C or D; I need a name. Were these positions advertised? I need transparency on that. Was there an interview process? Were there decreases or increases in salaries or anything like that? Who carried out the whole process from start to finish? That is one little group of questions.

Going back to what Deputy Neville said a while ago about accountability and transparency and where the money is being spent on new services, I am sure the witnesses are right, but we are not seeing it at the front. Two weeks ago tomorrow I was in Clonmel. There were 300 people at the meeting, and to hear the stories of non-existent mental health services would absolutely break one's heart and soul. A 60 year old man has to find his own way from Clonmel to Kilkenny. While his paperwork - his own documents, his own life story - are being taxied from Clonmel to Kilkenny, he finds his own way. Once he was released from Kilkenny, he had to thumb his way back home. There is certainly something wrong when it comes to services. That is only one point. Mothers are revoking their sons' bail because the poor young fellas are safer in jail than being left out in Tipperary as the services are not there. It is not about who said what; the most important thing is that people around this country are really suffering. I am trying to be as polite and diplomatic about this as I can. As for the knock-on effect on each person and family of this, they are not statistics. They are human beings. I cannot reiterate this enough. There are schools where it is now normal for kids to hear every four to five weeks of another parent of a child dying by suicide. It is not the children.

There is a line in a recent reply Dr. Shari McDaid of Mental Health Reform received from Tony O'Brien about restructuring the establishment of the mental health division. Can any of the witnesses explain what the former head of the board meant when he said this?

Having developed a strong delivery system through the introduction of Community Healthcare Organisations and Hospital Groups, it is important that the role of the centre changes to one which supports and enables the delivery of services as opposed to actually delivering services.

This does not mention improvements or outcomes. It certainly does not mention patients. The point I am trying to make about this is that if we need to do something right, we must start right. This is not a personal attack on any of the witnesses. If they could answer those questions, I would be very happy. In the last paragraph on page 2 of Mr. O'Sullivan's opening statement, it states "to build a better health service and to strengthen governance and accountability in the service". I am not being disrespectful, but the majority of speakers who have spoken before me are not getting any answers. All I am getting is frustration. When it comes to figures and moneys, the increase in expenditure on mental health since 2013 is from €709 million to €867 million. If one were to do the maths, between 2013 and 2018, it is an increase of €1.32 million a year. Is that an overall increase within the mental health services or is that €1.32 million over the whole health service, after which the mental health section is pulled in? I am fairly confident in one of the CHOs from one of the budget reports that we did get that €447,000 was spent on taxi services in one area last year. There is no accountability, and €447,000 is a lot of money. I understand files can be transferred but, Janey Mac, it can surely be done some other way. It seems to be about spending money to make money for someone else. There is no such thing as spending money on the patients for a better outcome to save society stress and cost. Do the witnesses understand where I am coming from? I am frustrated. I would be very happy if they could answer my questions. I will be very disappointed if they cannot because, to be totally and brutally honest with them, if we cannot have accountability and transparency here, we are absolutely wasting our time.

If Mr. Sullivan is relatively new, is he the appropriate person to answer Deputy Buckley's questions?

Mr. Dean Sullivan

I believe I am. I will certainly kick things off. I will ask Ms O'Connor and other colleagues to come in on the delivery side of things.

I will deal with the appointment stuff first. This is very straightforward. A post at the level at which I joined the HSE must go through the public appointments process, so all of the assurances one would expect to be in place around that are in place. The post was advertised, there was a very comprehensive recruitment process, an assessment process-----

Was it internally or publicly advertised?

Mr. Dean Sullivan

I did not come from the HSE; I am from another organisation.

It was advertised publicly, then.

Mr. Dean Sullivan

Yes, it was advertised internationally, as I understand it. There was a strong field of candidates, I was fortunate enough to be offered the post and I took it. Again, I am happy to provide further detail-----

Please do.

Mr. Dean Sullivan

-----rather than take up Deputy Buckley's time.

Will Mr. Sullivan provide detail relative to his colleagues as well?

Mr. Dean Sullivan

As for my colleagues, John Connaghan was appointed at the same time as me. Colm Henry's post is an interim post of chief clinical officer, but the intention is that that will be run publicly later this year. That is my understanding. All of that will be run through a formal Public Appointments Service, PAS, process. As I said, if the Chairman or Deputy Buckley need any further information about this, I am happy to furnish it, but as a process it is, as one would expect and wish it to be, a very comprehensive one.

Regarding some of Deputy Buckley's frustrations and the role of the centre, for the absolute avoidance of doubt - and I know I speak on behalf of my colleagues here - the Deputy may think we are trying to be obtuse or not to give straightforward answers, but we are absolutely not. Sometimes we just cannot give straightforward answers to the questions asked because there is no straightforward answer to them. However, it would be wrong for him to assume that this is us trying to be clever or obtuse or to talk around the subject. We are not. Equally, it would be wrong for him to think we do not absolutely, categorically have patients at the absolute centre of all we do. Sometimes there is a risk with conversations like these that we get lost in the undergrowth of very small detail and miss some of the bigger picture. The bigger picture is the point I made earlier. The question is whether €15 billion is enough to provide the health and social care services that the population of Ireland wants and needs. I am too soon in the job to reach a definitive view on that. I see areas where there is definitive pressures within the system. Doctor numbers are definitely light in Ireland compared to elsewhere in Europe. I am not sure at present whether €15 billion is enough. Even if we park that as an issue, I think the proportion of spend on specialist mental health services is too low within that overall side of things. The manifestation of this is that within particular areas of service - and CAMHS is a key one, clearly, but there are others as well - the extent of patient need exceeds our capacity to respond to that need.

I beg Mr. Sullivan's pardon. I must leave to vote on the Mental Health (Amendment) Bill. Deputy James Browne will take over for a few minutes. I ask Mr. Sullivan to forgive me for interrupting him.

Mr. Dean Sullivan

No problem at all.

Deputy James Browne took the Chair.

Mr. Dean Sullivan

If I may continue, the extent of need exceeds our ability to respond to that need.

None of us likes that. I am not happy about that being the position. I suggest it might be a fruitful course of action to ask if the committee is satisfied that we are doing everything we can with the resources we have to maximise capacity to respond to that need or not. I do not doubt there are opportunities to spend money differently or for the staff we have to be more productive than is sometimes the case. Will that, in one leap, bring child and adolescent mental health services, CAMHS, capacity to the demand for CAMHS such that patients, as they should, have timely access to high quality services across the country? It will not. There are not enough resources in CAMHS to provide the timely access that is required. We can all spend a long time working out whose fault that is and whether expenditure of €400,000 on taxis fixes that. We will have a more productive discussion, hopefully one that the committee will be less frustrated by, if we take it up a couple of levels. If those fundamentals are not right and the €15 billion is not where it needs to be, or the subset of resources directed to specialist and non-specialist needs of mental health patients is not where it needs to be, aside from all the wider societal factors that are driving those needs, then it does not matter how I or other witnesses respond to the committee's questions. It does not matter what finance information systems we have because it is still cutting a problem. We just have a better understanding that it is a problem as opposed to fixing it at source. I do not want to use too much of the committee's time but I would not want it to have any sense that we are trying to be obtuse or to frustrate the process.

It is not a personal attack but it is nice to know where one stands at the start. We have had comments from the Minister before that money will not be a problem when it comes to staffing. There is a lack of communication. Surely if there is a waiting list of more than 2,300 people, the board can go back to the Minister - not a Department, because it will get lost - and make a direct appeal for additional funding. It could say it knows that the current budget will not be enough but that more than 2,300 children have certain needs. It knows how much it will cost to meet these needs and could ask that the additional funding be ring-fenced for this purpose. I am realistic about this because I know the services are squeezed to death. At least there would be forward planning, money would be ring-fenced and the problem would be boxed in, which would allow the witnesses to look at breaking down some other system. Is that possible in the future with this new forum and set-up?

Mr. Dean Sullivan

As the Deputy will appreciate, there are maybe 60 different examples of things that are as much an issue, as risky and as difficult for patients and their families as the CAMHS waiting time. I assure everyone that we will make the case that where there are demonstrable capacity gaps and needs are not being met, we will seek to secure additional resources. If we can get all of those covered off, that will be fantastic, but it will probably be challenging for the Government to provide sufficient resources within a short timeframe to allow all of those needs to be met. In the absence of that, we will have to try to make demonstrable progress across a smaller range of areas to stop the problem getting worse and then to begin to make inroads. I take that on board.

This question may be very cynical. In the next five years, we are looking at maybe 1,700 retirements within psychiatric services. We have a backlog or void caused by approximately 500 positions that have yet to be filled because people cannot be recruited. If the service is already short 500 staff and 1,700 more are set to retire, a shortfall of 2,200 staff could arise within five years. If we do not address this gap in the next five years, will there be an emergency in the service? Can the witnesses see it imploding or just disappearing?

Ms Anne O'Connor

Staffing is a problem; there is no doubt about that. We have funded a postgraduate training course. We had our first cohort of graduates from UCD in postgraduate nursing. They are people who converted from other types of nursing into mental health. That course is continuing. We have increased our undergraduate training. We are looking at how we can fund all sorts of initiatives relating to education.

There are a couple of things relating to the sustainability of our model. We have a need for specialist staff in our services. We need to introduce skill mix to our services and to ensure that our most skilled staff are being used to work at the top of their licence and that we introduce other types of staff. That is not straightforward. We also have to look at the model of how we work. If we want to address the challenge relating to young people's mental health in Ireland, the conversation cannot just be about CAMHS. That is the end of the chain. We need to invest in young people's mental health in schools, communities, primary care and all the other areas we talked about to improve that. CAMHS will never be able to cope with the demand that is coming its way unless we get involved earlier in stopping that flow. It is about all of the things the EU task force looked at, including building resilience among young people in Ireland. That needs investment. The conversation on mental health and young people has to start there.

We have to focus our specialist services on people who really need them. None of us is happy that we have so many referrals coming to CAMHS. When we look at them recently, we found that up to 40% of referrals are not really for children who need CAMHS. These are children who are being referred to CAMHS because we do not have other options available. That is why we are investing in psychology and primary care and looking at how we work with other funded agencies such as Jigsaw and SpunOut to see how we can change the conversation around mental health. We will not meet the needs of our sickest young people if we are trying to manage this massive demand that is inappropriate for a service of that kind. CAMHS is a specialist secondary mental health service. It should not become a catch-all for any young person with a mental health difficulty and none of us would want our children to attend a psychiatrist and specialist mental health service just because there is nothing else. That is a really important conversation.

I thank the witnesses for their attendance. I wish Mr. Sullivan all the best in his role. It is my intention to work with him to try to improve services and to be of assistance by pointing out system failures. I have no doubt about the commitment of any of the witnesses to their roles. Sometimes, capacity and the sheer volume of what needs to be done makes it difficult.

On recruitment, the lack of a sufficient number of staff across every CAMHS team was pointed out to us. Very few teams are at full capacity and in many of them two or three key roles have still not been filled. For example, if a psychiatrist is not appointed, then everything further down the chain slips. Referrals continue to be made upwards but the person who makes the key decision is not in place. Every part of the team is key but if there is not a full team, it is very difficult to make progress and clear the waiting list. I believe there is an issue with the recruitment agency in the HSE, the national recruitment service, NRS. Work needs to be done to improve the operation of the NRS to ensure staff are at least in place and full teams are operating to try to clear the backlogs.

Does what the witnesses have laid out in the statement coincide with what they would call a clinical care pathway for any child or adult with mental health issues? For me, dealing with people, that is what I would like. If a parent comes in with a child who is having difficulties accessing the services, I would like a flow chart showing that care starts with the general practitioner, GP, and setting out where the person goes from there, and so on up the line. As a public representative, I would then know where and whom to contact to find out what is delaying a case.

Sometimes I feel great frustration in that I cannot seem to get help for someone because I am unsure where to start or finish. I get lucky sometimes when I get a helpful person at the end of the telephone. I would like to see the clinical care pathway for children and adults. That would be helpful for me as a representative of the Cork-Kerry region. I imagine the same applies to other Deputies and their respective regions. Is that what this is? Is that in place?

Ms Anne O'Connor

Does Deputy Brassil want me to answer now?

Yes, if possible.

Senator Joan Freeman resumed the Chair.

Ms Anne O'Connor

A couple of points arise but the question is where to start. Deputy Brassil asked about the care pathway. The first place for any young person to go is to his or her general practitioner. A child or family who are struggling should go to their GP. We hope the GP would know which services are available locally. The problem we have - this was correctly pointed out by Deputy Brassil - is that teams are not fully staffed and we do not have enough teams. The child and adolescent mental health services operate at a little over 50% of what A Vision for Change set out. We are not going to have the gold-star CAMHS using that model.

This brings me to the fact that in Ireland we have a way of working that is tricky. Our policy says that every young person should have a named consultant. There may be a view that this ties us up in knots sometimes because the consultant has to be involved in every child's care. What happens if a child does not have a consultant? Other team members might be available. Our system is not similar to that in the UK, where it is not about having a named consultant. That is a challenge for us in terms of how we deliver our services.

It can be changed.

Ms Anne O'Connor

It can be changed through the review of A Vision for Change but it is a Mental Health Act issue more than-----

Mr. Jim Ryan

Deputy Brassil raised a particular point. One thing we have done relates to putting standard operating procedures in place for our CAMHS teams. I can send the link to the Deputy. Essentially, the website shows the pathway of care for a young person from the GP. It not only refers to what happens in CAMHS but also sets out the alternatives available to the young person and the family in advance of going to the CAMHS team.

One other thing may be of value. On Monday, we launched a series of videos to outline the pathway for young people who are attending CAMHS. The yourmentalhealth.ie website contains a link to 16 videos that have been produced between the HSE and SpunOut.ie to give a description using plain simple English of what a person can expect when attending CAMHS, what he or she can do in advance of attending CAMHS and if the person is on a waiting list. We have done this with the involvement of young people as well as parental involvement. I recommend the site for any committee member, Deputy or Senator. It would be useful to look at it because it is a simple and easy way for people to understand what they can expect. I believe that will prove beneficial. The standard operating procedure is helpful from the point of view of explaining what CAMHS does and does not do. Both tools are available online.

Ms Anne O'Connor

We are working with the Irish College of General Practitioners and CAMHS on this and we are conscious of it. Part of the problem we have is that referrers will send multiple referrals across the system because they do not know what service they will get. We see large numbers of duplicated referrals. One challenge is to look at that. As recently as this morning we had a meeting to look at how we can create a different approach. We are keen to build on some of the work we have done with the approach around youth. Again, the conversation is around youth mental health rather than simply CAMHS and that is relevant. We cannot assume that if someone has a mental health difficulty he or she should simply go to CAMHS. We have to build that into our conversation as well.

I would appreciate it if Mr. Ryan would send the link directly.

I wish to make one last point. All of us have come across examples of people who get into the system, get treated, get well and then relapse. By and large, the experience is that such people go right back to the start of the system they have already been through. It is frustrating because they can finish up but find it difficult to get back to the place where they were treated and got well the previous time. Work needs to be done to look at how people who have had previous history and a different starting point can return. CAMHS has experience. This is what I find when dealing with constituents. They may be going great. Then, they come to me and ask to get back to X, Y or Z, who got them right. However, for the person to get to that point, he or she has to go through a big long rigmarole and that is frustrating. That would be useful.

Ms Anne O'Connor

I will take that away. That should not be the case.

I welcome the members of the deputation. I realise it comes across that we are trying to score points and so on but it is not about that. We are simply trying to get greater understanding. Many of us believe the system is broken and needs to be fixed. What we are trying to do is come up with avenues to get there. We need to work together in that regard.

The last speaker referred to frustration with the structure of the system. I believe that frustration is shared by all of us. Part of the difficulty is that we build a relationship with a person in a particular area and then the person is moved. Simple things like trying to get through by telephone or email can be difficult when the number or the email address changes and so on. These are simple things.

We seldom get cases where everything is going great. The members of the deputation know all of this. No one comes to our offices with a simple question. We get the problem cases or those who do not fit in and so on. At some stage I would like to hear more. The HSE representatives have referred to improved access to services, more consistent support of service users and so on. I would like to hear the more on this at some stage. I am unsure whether they will have time to elaborate today but that is one conversation we need to have. What improvements will materialise?

I imagine some simple things could be fixed. I will offer an example since examples are probably the best way to illustrate the point. I was dealing with a woman who has two teenage children in services. She has never got respite when the two teenagers were in at the same time. She can only get respite when one is in, so she does not really get any respite. Is something like that difficult to fix? I am unsure if the HSE representatives have ever come across something like that. It should not happen in that way. An appropriate remedy would transform the life of that woman. That is only one case.

Access to services is another area that needs attention. We come across children in need of speech and language therapy. One person was waiting three years for speech and language therapy and another three years for grommets. We are discussing the mental health of the child and parents. If a family is waiting that long for the services it has a major impact on the children. Are these children seen as a priority for the HSE? I am looking to hear from the HSE representatives today rather leaving on a sour note of them-and-us. Clearly the structure is not working at the moment and a new structure will be in place. What are the priorities of the HSE in the next 12 months? Can we bring back the deputation in 12 months' time – provided the committee still exists – to hear what has and has not worked? That would be helpful for us, especially for people at home who are watching. They are probably screaming at the television asking why we did not ask this or that question. People want to know. They hope the system will change for the better.

Ms Anne O'Connor

The first part the question was around user engagement. That has been a priority for us. We actually carried out listening exercises with over 2,000 people in 2014 to find out what service users and their families wanted from our mental health services. We went to approximately 28 locations nationally. The feedback was clear. It was about service users being more involved and having a greater say in their services. With that in mind we established a reference group to look how we could hear the voice of service users. This can be tricky. We cannot simply pick someone to be the voice of service users. We looked at how to develop a structured approach to service user engagement. From all of that, we appointed Liam Hennessy, who is the national head of mental health engagement. He heads up a function to look at how we work with service users and their families. Then, we moved to appoint a head of engagement in each of the nine community healthcare organisations. Mr. Hennessy sits on the mental health management team. The heads in the local areas sit on the mental health management team. Their job is to ensure that service users are at the centre of everything that goes on.

There is no quick fix to all of this. It is taking time and it will continue to take time.

What we know now is that if we have service users sitting at all those tables and as part of all of those discussions and we look at everything through a recovery lens, we have a much better chance of meeting the needs of what people want and what is meaningful for them. We also moved from that into employing peer support workers, which is the first time that has happened in Ireland. These are people with lived experience of mental health who now work and are employed by the mental health services. They work with other members of multidisciplinary teams to support people in their recovery. All of those things are being viewed very positively. We have very positive feedback from service users around that. We are rolling that out. To date, we have 28 peer support workers in the country and the number is growing.

I could not agree more with what was said about our approach to children in general. There will be an impact on the mental health and educational achievements of any child waiting for speech and language therapy or other service. Within the disability space we are looking at how we can improve services for children who have disabilities and other conditions through the development of children's disability networks. We have a very exciting initiative that we are progressing with the Department of Education and Skills around the employment of in-school therapists in one part of the country. We are employing speech and language therapists and occupational therapists to work in schools with teachers, looking very much at the early intervention piece.

There is a number of initiatives across the disability space that will complement our work because as we know the reality in mental health services is that many children present for CAMHS who have had experience of speech and language difficulties as well. There is an overlap there. We also have the assessment of need process in disabilities as well. All of those are fairly joined up and our challenge is to look at how we can address what is often a very significant waiting list for children to receive services and there really is a demand capacity issue. We just do not have enough to meet the demand that is now emerging in various parts of the country.

I hope that information is helpful to Deputy Crowe. On the feedback from service users, especially for children, I think a survey should be addressed to the warriors who are 18,500 parents who are really dissatisfied with the services that are available currently. Ms O'Connor is brilliant at accentuating the positive. That is what she should do but we also have to identify all of the mistakes and the brokenness of the system. I now invite Deputy O'Loughlin to contribute.

I wish Mr. Sullivan well in his work following his appointment. He was before the committee previously when we started this process. He was at some of the first meetings. I also wish Mr. Healy well in his new role as national director with responsibility for community strategy and planning. All the witnesses have an unenviable task ahead of them in the very important work they need to do.

I will try to avoid repeating questions that have already been asked. In his opening statement, Mr. Sullivan referred to tangible service improvements. We appreciate that more funding has been provided but at 6.4% it is far less than it should be. I understand that 11% is the guideline generally worldwide. Could Mr. Sullivan outline the exact tangible service improvements to which he refers?

Mr. Sullivan also spoke about the fact that there was too much focus on day-to-day activities and that the model is being changed. He said we need to focus on long-term planning and change. I agree with the need for long-term planning in mental health provision but we cannot take the focus off day-to-day operations, which is every bit as important.

Mr. Sullivan also spoke about integration with primary care services. I agree with that approach. In a previous meeting we learned that in an ideal world counselling services would be available in a primary care setting, but that does not happen in many areas. I agree there should be integration but I fear we are a long way from it, and while we are waiting to get to that stage there will be some gaps.

Ms O'Connor mentioned that we need to look outside of CAMHS and at working with the other groups that are there at a community level such as Jigsaw. There is no Jigsaw service in my county but we are anxiously awaiting one. Other such community groups that are in Kildare include SpunOut and Hope (D) which are doing really good work. I agree that the intervention needs to be at that level. I welcome what Mr. Ryan said about the videos and CAMHS. I look forward to watching the videos and pointing people in that direction. Parents and schools contact all members and they feel the elusive CAMHS is the answer to all their problems and it is not. We know that is the case. It has worked well for some but many people experience a lot of frustration in accessing CAMHS. It would be helpful if there was more clarity about what it can and cannot do and what other extra supports are available.

I have a specific question on the restructuring. We were given evidence previously that dedicated resources are needed within mental health to drive policy. I read Mr. Tony O'Brien's letter on the restructure but it makes no sense to me to remove the national director for mental health. We must have somebody within the HSE to provide dedicated leadership on delivering and improving mental health services around the country. At a national level who is going to deal with the delivery of mental health services and who will have the authority to consider the different priorities and give direction to the various community healthcare organisations, CHOs? I expect Mr. Ryan currently has that responsibility but I might be wrong in that regard.

Reference was made previously to the dedicated and separate national mental health budget. There is a fear that if the direct authority goes from a national director then the budget would also go and the setting of priorities and expenditure across the country would be affected.

Mr. Dean Sullivan

There are a lot of points in there. A couple of points related to the restructuring. One point was about the potential benefit of focusing on a longer term strategy with a loss of focus on day-to-day issues. I do not think the centre should be other than by exception focusing on day-to-day issues. I think that that rightly should be sitting out with the community health organisations and with the acute hospital groups and only by exception when they have not resolved them should they be escalated. A point was made earlier about the respite discussion, for example. In a situation where there is adequate respite capacity that clearly is a discussion that should be happening at local level between the local delivery teams within the CHO and the relevant families, parents, patients and so on. It is not a thing that we should be trying to run ahead of those responsible. That is why I focused on the HSE's central role.

In terms of the focus on mental health, I will come back to what I described earlier. Before the creation of my role within the organisation and then in turn the role of Mr. Healy working with me and then Ms O'Connor working with Mr. John Connaghan, there was not that overview of the wider picture in terms of health and social care funding and within that funding the specific priorities for a whole range of services. The focus there needs to be in mental health and in other areas on upstream investment to avoid the need to access CAMHS at all, as Ms O’Connor said. We were just looking up and down the individual silos. I genuinely believe there will be huge benefit in terms of how we plan and prioritise health and social care services as a result of this split. If I did not believe that I would not be here in this role. Having said that, if we turn this into just the creation of three new silos from the five or six that we had before that would be just daft, so we have to continue to work together. We recognise that the primacy for strategy and planning work within mental health and more generally will sit with me, Mr. Healy, and others. The primacy for ensuring that what we identify within plans is delivered will sit with Ms O'Connor and colleagues, but clearly we are not developing those plans and strategies in isolation from them. We will work in an integrated way. We have been and we are now. That is why we are here today in the way that we are. We will continue to do that. We still have the clinical lead that was mentioned earlier in response to a previous question. We all feed across to each other. He is giving mental health input into both my side of the house and to Mr. John Connaghan's side of the house on the operational side of things. I genuinely believe huge benefits can be secured from this structure.

That is provided we approach it in the right way and do not create a new set of silos to replace the old ones we have. There is nothing in the time I have had the privilege of in working with Ms O'Connor, Mr. Healy, Mr. Ryan and others that gives me any sense that would be the case. I come back to the point I made earlier that it is all about patients and clients at the end of the day. We need to do the very best we can within the resources we have. Sometimes we wander into spaces where we assume there is a failing within the system but the resourcing of the system is so far away from what it needs to be. We mentioned the 10% figure earlier and 10% of €15 billion is €1.5 billion. That assumes €15 billion is the right figure. In a world where resourcing for specialist mental health is hundreds of millions of euro away from what is needed if we were to get to the 10% figure, it is not surprising we have some of our difficulties. We need to address those difficulties not just by investing at the end point of the problem in CAMHS and so on, and it involves all the upstream services we mentioned.

I am not here today to lobby for extra resources for health at all but I ask for a degree of realism around where we find ourselves today in the journey in which we are on and the priority we will continue to give to mental health services.

Before getting to Deputy Neville, I ask again how we can ask for more funding when we still do not know how money is being spent. I am specifically referring to CAMHS.

I totally agree with the Chairman's comment. As the people who sign off on the budget, we are accountable to the public for that. From the specialist perspective, we would like to know what is being spent. I understand from an audit perspective the boxes are ticked on the back end and we have had this discussion, thrashing it out already. From the front end - I am making a decision as a stakeholder on how to spend the money - I cannot get the answer as to where it is being spent. It is extremely difficult for me to go to a voter then and say that X, Y and Z are being done. I cannot answer the questions coming back to me.

Do we want to see more resources put into mental health? I am not saying it does not need more resourcing but if new money is being given to it, we need to know where the money is being spent before we put more money into it again. It would be irresponsible to put money on top of other money when we do not know where it is going.

There was mention of a new finance system and I received an answer to a parliamentary question about a new finance system as well. I was told there would be a new finance system but I have been given nothing about timelines or the current state of the project. I have been given nothing about the cost of the project, whether capital, implementation or ongoing running costs. What budget will it come from? Will it be from the new money or existing budget? Is it being outsourced and what is the relationship in that process? The witnesses have said it will take a number of years to implement this but is it being built onsite or offsite? There are a number of questions to which we need answers. If the finance system is a shared system and takes a number of years to roll out, where exactly are we in the project? Is the HSE gathering requirements now or is it moving to the testing phase?

Mr. Dean Sullivan

I can get the Deputy a very comprehensive note on that. There is a separate project taking this forward. I know it is in the short to medium term list of priorities for capital spend within the information technology budget. It is not out towards the back end of the 2020s but in the coming number of years.

Could we get specific dates?

Mr. Dean Sullivan

We are certainly happy to do that.

There is also recruitment. I asked about this the last day and, without being disrespectful to those who were here the last day, they were probably not the right people to speak to us about recruitment. A flow chart was required of the end-to-end process relating to recruitment, how that recruitment takes place and how each stakeholder comes into the recruitment process. I am not discounting the comments of the witness regarding resources, and this is a particularly demand-led service, but I am not saying there are no failings in the system either. Let us call it out. It is not as if everything in the system is perfect either. We have started to turn that over here. I do not want it to go out that this is just about resources. There are systems failures happening as well and we must try to identify and fix them together. That is the reason for the robust questioning.

We need to know about the financing so we know where we are to spend the money. When I walk into the office of the Minister for Health, Deputy Harris, and ask him or anybody else how much is being spent on specialties, I should be able to get the figure. In the private sector a button can be pushed and a report can be run in order to get such figures. It is a massive frustration on our side, particularly when we see the likes of the childcare service rolling out a new information technology system. It is a massive bugbear.

There can be no response to that really as we will have to wait on it.

Mr. Dean Sullivan

We can certainly arrange a further briefing if that is helpful.

What are the figures for the clinical and non-clinical staff in the HSE mental health services? I would like those figures.

I have two supplementary questions. Earlier we spoke about early intervention. The last resource is CAMHS so every other intervention is before that. We are nearly six months into the new budget so what portion of the new mental health funding allocated by the Minister in that budget has been spent on other than existing resources? What is being spent on new projects? The money was specifically for new projects.

CAMHS is an acute service. We spoke about other services and the witness mentioned Jigsaw, which does phenomenal work. The Galway Youth Counselling Service made an application to the HSE for funding to extend services into Gort and Ballinasloe. The service is currently provided in Tuam and Loughrea but these people want to extend it across the county base and into Connemara. It would cost €112,000. This developed from Comhairle na nÓg four years ago. The service has psychologists who give talk therapy to a minimum of 200 children across the county. These kids are referred from schools and Tusla. It provides for children going from sixth class to first, second and third year. There is a gap in the system where there is anxiety and stress arising from transition. We can all relate to it. Six weeks of such support bridges the gap. The service made an application and it seems it was fortunate to get €15,000. The service will close at the end of June.

This is an identified service with associated statistics. Everything has a data basis, including age profiles, schools and demographic needs. It is a clearly identified new service that can support existing services within the HSE. I wonder how many more of them we are missing throughout the county that are providing a fantastic service, with accredited and qualified people providing support to schools. It is helping 200 kids and if the service is not there next year, they will go on a waiting list somewhere, blocking the system. Those kids do not need to be in any system but they need help in transition. This is why I ask how the new allocation of funding in the budget is being spent.

It is in the community healthcare organisations, CHOs. I have a letter from Mr. Charlie Meehan in my CHO refusing the full amount of funding. The HSE confirmed it was supportive of the group but indicated that, unfortunately, in 2018 mental health services were hugely oversubscribed with respect to section 39 applications. It was not in a position to increase funding to the group. I am not disputing those facts but with the extra allocation of funding given this year, I would have hoped we could have supported 200 kids in Galway.

Ms Ann O'Connor

I do not know the particular agency but the Deputy mentioned a few issues.

With regard to funding I believe we answered a parliamentary question on the allocation and spend in 2017. Our 2018 funding has not really been spent yet. Generally it is mid-year before we start spending that year's allocation and we are still working off 2017 funding, if that makes sense. The funding from 2016 and 2017 is going into the opening of new acute units, the enhancement of the acute units in Limerick, Galway and Drogheda, and into a high observation unit in Kerry. Acute care is at the upper end of costs. The combined cost in 2017 for those was €4.6 million.

In 2017, €3 million was allocated to primary care-based mental health supports such as assistant psychologists. These assistant psychologists in primary care are now employed. They are not there long enough to know the impact they are having on the child and adolescent mental health services, CAMHS, side of the house.

We have enhanced the Jigsaw funding and we have improved patient safety by looking at additional posts, especially in some of our more acute units. We are doing a lot of work in our forensic services looking at prison in-reach. We have the largest capital project ever in mental health in Ireland advancing very quickly in Portrane, which is the new forensic hospital.

We have developed our eating disorders services with a number of teams, adult and CAMHS, for eating disorders. There are all of these different services, including peer support, and part of the challenge is that when one refers to €20 million or €35 million it sounds like an awful lot of money but when one considers the nine CHOs and the specialties in CAMHS, general adult and psychiatry in older life and some of the more marginalised groups such as people who are homeless, Travellers, forensic services - which is also high-cost - the funding goes quickly. We must balance this out to try to raise all the boats.

Parts of the State are very highly resourced and when we consider the average funding across the State, and I hate to break it to the Deputy that CHO 2 is actually quite well funded compared with a lot of the other areas. There are other areas that have never had a psychiatric institution and do not have the pot of gold that some areas have, not that it is enough now. However, areas such as Kildare, for example, come from a different place.

That is our challenge. We cannot turn off services. We have to keep services going and continue to enhance them.

I totally agree with Ms O'Connor and I do not dispute one thing she has said. In her statement Ms O'Connor said that the service is still spending the funding from 2017. Is the 2018 money that is in the pipeline going to be too late for some services that are trying to penny-pinch to get them through to the end of the year?

Ms Anne O'Connor

The new funding in 2017 was €15 million, with a further €20 million committed in 2018. It was the full-year cost in continuing that. It is all phased. There is €15 million in one year that grows into an extra €20 million the following year, but they are the same initiatives.

Yes. On the issue of the same initiatives, what about the new groups that provide the services? As elected representatives, can we tell them to hang on, as it will get better next year or that because there may be a few euro coming next year, they can continue to provide the invaluable service they provide?

Ms Anne O'Connor

As for the service, such as the example described by the Deputy, that is part of our approach to youth mental health. We are looking at this area and we have already mapped a lot of agencies. Our challenge around some of the counselling supports for young people is that they are funded either by us, by the Department of Children and Youth Affairs, by Tusla or by lots of other potential funders. We are trying to figure out the best approach. A certain amount of service provision is appropriate to be done nationally. We work with Jigsaw nationally and it identifies the priorities but I do not know the best solution in Tuam, Clifden or Carraroe; we rely on the local teams and local services to identify priorities. We must put the right structures in place. We are looking at this with regard to how we can have somebody within a CHO whose job it is to look at the local need and the local provision to try to enhance the supports, on the basis of knowing what is there.

I have one last question on dual diagnoses. I do not mean to say that it is a problem specific to Galway currently, but I refer to the issues for a child who has autism in my area. The Galway Autism Partnership, GAP, group, had come under the mental health services but must now change how it does business, perhaps because it is in the wrong space. There is a transition of moving the children on to a different level, but a lot of children who have not yet had an assessment are now in sixth class and are going into first year of secondary school. Parents are panicking. Will there be support and funding from the mental health services? Will funding be left to support families and children with dual diagnoses?

Ms Anne O'Connor

When a child or an adult has autism we are not about turning off services. I believe that this service in the west was inappropriately located within mental health services. In the rest of the State it is more in the disability space. We are looking actively at how we improve services; we have examined all autism services nationally to see how we can improve them. We are working with people on this and we have reviewed it. I am not sure about what service has been turned off. They should not be without a service if they have had a service previously-----

There is a transition taking place, with some children never having had an assessment. There is concern, especially among the parents of sixth class children who are now going into first year, that their children have not received assessments.

Ms Anne O'Connor

I can take that away and check it later.

That would be really appreciated. Parents understand that it has to move and what the HSE is doing in this regard but we also realise that we cannot have children moved who have not had their assessments and who have been on the waiting list for some 18 months.

Mr. Pat Healy

In the future, working from a strategy and planning perspective, we will be looking across all the care groups such as primary care, disability and mental health. There is opportunity and potential, within the structure we are referring to, to break down those boundaries and barriers for transition to happen in a more joined up way.

Is it the case that when there is one entry point one can access various services?

Mr. Pat Healy

That is what we would try to do in the future and to make a much better link between general practice, primary care teams locally, disability network teams and the mental health services to join up the dots. While the silo approach has its benefits, the joined-up integrated way offers a lot of opportunities for the future.

Is the HSE conducting a pilot of this anywhere?

Mr. Pat Healy

There is actually a network team and a pilot has been done on autism and disability services. I hope that what has been done in rolling these out will take account of the transition the Deputy referred to.

I thank Deputy Rabbitte. When Ms O'Connor provides Deputy Rabbitte and the committee with that information, will she also give a timeframe?

Ms Anne O'Connor

Is the Chairman referring to the transfers?

Not now but when Ms O'Connor is sending in the information. I apologise to Senator Devine. There was a list before me and this is why she is at the end. Please go ahead.

That is okay. There is a small article on the budget. I am aware that the witness has said that she expected to answer more questions than to present. It is a political issue because it is a crisis. Given the explosion in the population and the increase in demand by those in emotional distress and by those with diagnoses of mental ill-health, I believe there should be a request or a demand for a lot more finance for mental health. It was an opportunity to make a statement on that.

Ms O'Connor referred to the new eating disorder service. Where is this exactly? Is it operational yet?

The Central Mental Hospital is mentioned on the last page, page four, where it appears to come from the national budget. Is this part of the budget of every CHO? Perhaps the witnesses will explain to the committee where that budget comes from and how it operates, given that the waiting list is 35 people who have had a five-year wait, at least, to be transferred to the Central Mental Hospital.

Everything has changed. It has utterly changed after what has happened in this State in the last two weeks. This is the elephant in the room here. I am aware that it is not our place to ask questions in that regard and I do not intend to, but it is the backdrop to and atmosphere around the confidence within the HSE.

The HSE board is to be re-established. I have tried to work on the issue of service users and patient participation in decision-making tables but I have been getting blanked by the HSE. Ms O'Connor referred to the issue.

We need patient participation on every level and we do not need it to be sidelined into some focus group. We need transparency and the HSE needs to have the checks and balances that are provided outside the health profession. The Minister needs to put his stamp on this more firmly. Effective public participation yields changes in behaviour and in culture but there is a significant lack of trust at the moment.

I often feel that committee members ask questions and the HSE responds but something in our communication is missing and we are not getting through to each other, although I am not sure what it is that is missing. We ask simple questions on behalf of Joe and Josephine Soap and if we cannot get through the barrier, they obviously have no hope. The communications department of the HSE has been in the news. We are all here to work together for an improvement in our public health service. How does the communication department work in the mental health division?

Mr. Jim Ryan

One of our clinical care programmes has been established in south west Dublin and the intention is to roll it out nationally. Of the 20 new child psychiatry beds in the new children's hospital, eight are specifically for those withy eating disorders.

What is the timeframe for the eating disorder service?

Mr. Jim Ryan

Elements of it are already in place. We have allocated additional funding for 2017 and 2018 and it is being rolled out as we speak. I can come back to the Chair with more details on the specifics if she requires.

It is based in Dublin south west at the moment.

Mr. Jim Ryan

It is based in Cherry Orchard.

Ms Anne O'Connor

A start-up team for CHO 6, CHO 7 and part of CHO 8, which is the CAMHS southside area, has been funded. There is also an adult service on the southside. We targeted the south side of Dublin for CAMHS and adult services. That is partly to do with the fact that St. Vincent's Hospital has a history of eating disorder service provision. Part of the challenge with eating disorders is that it has to be connected into acute services as well. We are looking to work in Cork too and the clinical lead for eating disorders is based there. We are looking to enhance hub and spoke models where a hub is based close to an acute hospital with a specialism in gastroenterology, and the spokes are the community services.

Mr. Jim Ryan

At the moment, capacity at the Central Mental Hospital is 94 beds. There are waiting lists from the prison system and from our acute units.

There are shortages.

Mr. Jim Ryan

Yes. We are working to recruit the additional nursing staff, which are the only staff we have need for at the moment. We have consultants and multidisciplinary teams and our hope is that the graduate nurses in September will allow us to fully open the additional ten beds. We hope to open four additional beds by using overtime because the demand is there. One of the reasons for additional demand is the Criminal Law (Insanity) Act 2006, which means that people who are found not guilty by reason of insanity have to go to the Central Mental Hospital. The numbers of people who are found not guilty by reason of insanity have increased year on year so a bed is taken for four or six years, leading to capacity restraints. Staffing is the major issue, not funding or building.

If funding is on a national basis, how is it divvied up?

Mr. Jim Ryan

The Central Mental Hospital has a specific budget and reports directly to me.

Is it separate from the mental health budget?

Mr. Jim Ryan

No. It is part of the overall mental health budget but is separate from each of the nine CHO budgets. It is like a tenth CHO. It will be replaced by the new facility at Portrane in 2020, which is a significant new project requiring additional staffing. We will go from 93 or 94 beds up to 170, with additional specialties around CAMHS and forensic services and an intensive care rehabilitation unit. A project plan is in place and an external support organisation will work with us over the next 18 months or two years. It is a big piece of infrastructure but there will also be a significant change and transition programme for staff, patients and carers in the forensic service.

What about patient participation?

Ms Anne O'Connor

We should have patient participation and service user participation across the board. We have done more in mental health than in lots of other areas because we have a structure and have developed a new way of working with service users. We need that engagement across health services and the chief clinical officer will be dealing with that. We have invested significantly in that because we believe that without service user engagement the mental health services will not meet people's needs.

Is it possible to talk to the interim director general about putting this issue on a steering group for children with complex medical needs? Seanad Éireann passed a motion on this but the HSE is sticking two fingers up in response and is saying it will do what it wants. I am trying to represent parents in really difficult circumstances.

Ms Anne O'Connor

We are looking at a steering group and a parental reference group is being set up.

That is a sideline issue.

Ms Anne O'Connor

We are looking at parents from that group sitting on the steering group.

Wow. That is news. What about communications?

Ms Anne O'Connor

There is a lead for communications in the mental health division who has done a lot of work with other agencies. We are always trying to communicate and it is a big challenge. Part of the problem is that we need everybody to communicate and people have to communicate with referrers in local areas. We have published a lot and all the documents we have referenced are on the website. We try to get as much information as possible out there. There are different worlds of information. There is information that families want about family members, which needs to be very clear, and there is information wanted by professionals, other services referrers. We try to manage all that but we do have dedicated communication support for mental health.

I will summarise what we are looking for in a moment. Why does the HSE never implement or listen to the recommendations in the thousands of reports that have been done on mental health services?

Ms Anne O'Connor

We actually do. We have implementation plans regarding Connecting for Life, the most recent policy on mental health. We have a very clear plan that has been launched in each of the nine CHOs. It is cross-sectoral and is across all functions in the HSE.

Only approximately 50% of A Vision for Change has been implemented. How many years is it since it was published?

Ms Anne O'Connor

We have implemented it in line with the funding that has been made available to us. The policy is now being reviewed in the Department.

I am aware that it is being reviewed. It is a review of a review of a review. I am curious about the thousands of reports. There was a magnificent cognitive psychiatry piece on the recruitment and retention of clinical staff. I do not suppose there is an answer.

Ms Anne O'Connor

We do listen and we have met representatives of the college. We are looking at how we can recruit and retain consultants too. We cannot necessarily follow all the-----

How long has this been going on? Ms O'Connor is putting a positive spin on it. She says that the HSE is looking at it and things are about to be implemented. We need to know when that will happen.

Ms Anne O'Connor

We have said clearly today that we do not have the resources available to implement everything we want to implement. That has not been a great thing today and we are dependent on the funding we get.

We do not know where the money is being spent in some areas.

Ms Anne O'Connor

We know.

We are looking for the CAMHS spending down to the last penny.

Ms Anne O'Connor

That is on the record from previous meetings giving the money or information we can give. We will give the committee the briefing on the financial system.

We find that a little bit-----

Mr. Dean Sullivan

We also need to be clear that we are aware of the overall budget around that which is committed to specialist mental health services and we are aware of the budgets in other areas. We are aware of the staffing involved in the delivery of CAMHS services and of the activity that the staff should deliver and of the demand for those services as distinct from the need for them. Forty per cent of the demand could potentially be met in a different way.

Returning to some of the discussion with Deputy Buckley, it is entirely reasonable and it is the committee's role to hold us to account for delivering what we can reasonably do. The engagement becomes less valuable when we wander into matters where, bluntly, there is no chance of it. If the Chairman sends me to Tesco today to buy €100 worth of food and gives me €70, she will be disappointed.

We would not be if Mr. Sullivan could tell us how he spent the €70 and came back with a receipt. I am sorry, Mr. Sullivan, but this is a pointless argument because we have asked this question over and over. Deputy Browne wants to ask a question now.

The witnesses say CAMHS is being implemented in line with funding but it does not have the resources needed. Are the witnesses satisfied that they do not have sufficient funds, that funding is a blockage in delivering CAMHS?

Mr. Dean Sullivan

I will answer first and Ms O'Connor will give the detail on all of this. It will not matter whether it is CAMHS, or any other specialist mental health service or any other service for health and social care in Ireland, or anywhere else on these islands, or in Europe, there will always be opportunities to do things more efficiently and effectively than they are being done now. It is my understanding today that even if we were offering some perfectly efficient frontier performance it would fall well short of that which is required today. We need to be clear about what is reasonable in the context of available resources and what is beyond what can be delivered.

Ms Anne O'Connor

Funding is a difficulty. We can tell the committee the number of staff working in the area and the cost of that but that does not give the full cost because it does not give the cost of some of the governance around the services, or the other costs embedded in a wider mental health budget. We can give the committee the cost of pay for CAMHS. We would like to have more funding to give other agencies as well so that it is not just a question of CAMHS and a discussion about recruitment. We need to work with partner agencies, we need to have more funding to give them. There is a deficit there. We would of course like to have more funding for that.

There is an agreement that €55.4 million will be provided in this year's budget and that it will be facilitated in a multi-annual budget. I understood the Minister to mean that CAMHS would prepare to spend that money now and the full amount could be expended after next October. Is that being communicated to the witnesses and how are they preparing to spend that money? There should be no time lag, the money will be made available from October or December, whenever money is made available, and there will not be the usual time lag in expenditure.

Mr. Jim Ryan

We received €35 million full year funding, of which €15 million is available in year one in order to start the initiatives. That would equate to €35 million full year spending in the following year. It takes time to recruit and develop the services. That has been our process over the past few years, where a certain amount is given in year one, or whatever, and the full year is €35 million. In that way we know what we can spend on new developments and services.

Deputy Neville spoke about the difference between investing in existing infrastructure and new infrastructure. If there is a CAMHS team of 13 clinical people, and there are eight in order to bring that up, that is a service improvement as distinct from a new service. That is one of the ways we are trying to say service enhancement is to improve the service we already have and new development is putting in a new team. Sometimes we might put in a team of eight or six to begin the process. Some of that has to do with infrastructure and there are other reasons.

Ms Anne O'Connor

Funding infrastructure is very important. In some parts of the country we have very poor infrastructure. We have some wonderful new primary care centres that will accommodate services.

We are moving off the question. Has the Minister for Health communicated to the witnesses that in the upcoming budget €55.4 million will be made available from day one and that they are to start preparing to spend that money now so that there will be no time lag next year?

Ms Anne O'Connor

The Department has indicated that there will be funding available next year.

Did it indicate that €55.4 million will be available and the witnesses are to start preparing to spend it now?

Mr. Jim Ryan

This year we are spending the €15 million and it will be €35 million next year.

I have asked a very straightforward question and the answer is either yes or no.

Ms Anne O'Connor

We would not normally be notified of the budget allocation for next year before the budget. There is an indication that there would be funding available.

Have the witnesses been instructed to start preparing to spend it now?

Ms Anne O'Connor

We have done some preliminary work examining the initiatives we would want to progress next year but we will do that as part of a planning process anyway.

Why are there more than100 nurses on the CAMHS waiting list looking for jobs?

Ms Anne O'Connor

They are nurses on a panel. That does not mean they are not working.

They are looking for jobs in CAMHS, is that correct?

Ms Anne O'Connor

We have considered this in respect of the nurses we have. That is the number of people on panels. They are not necessarily looking for a specific job in CAMHS and are not all able to move. There is a geographical issue, for example, we generally find that we have nurses on panels outside Dublin and our vacancies are in Dublin. We have to have a geographical match between where nurses are on panels and where the vacancies are. Generally speaking, when it comes to mental health nursing we have vacancies in the east and we have staff in the west and the south. It is often the reverse for medics.

At the moment when children are transferred under a High Court order to the UK that is done under an EU regulation. There is a separate agreement with the UK for adults. Are preparations under way in the event that regulation falls following Brexit?

Mr. Jim Ryan

We have had some conversations on that with the Department of Health because we were asked about the implications of Brexit, particularly for children under the regulation the Deputy mentions. Some patients have a forensic history too. That conversation is live with the Department.

I understand from an answer the witnesses gave to Deputy Rabbitte that the Department felt it had no input into the changes made at the director’s level in line with Government policy. What exactly was its role?

Mr. Dean Sullivan

As I recall the question that was asked was whether there was any input from any third parties in making the change to having a separate strategy and planning arm within the organisation, distinct from an operations delivery arm and a clinical arm but all three working in an integrated way. I talked about my understanding that there was certainly a discussion between the Department and the top of the HSE on what it was trying to achieve and that in due course thereafter the advertising of the two posts to date, mine and the deputy director general of operations post, went through the full Department of Public Expenditure and Reform, Public Appointments Service, PAS, process. Unless I have missed seeing it, there was no formal approval from the Department of the structure. It was one of many matters that would have been discussed with the Department at the time. I am sure there would have been approval in writing from the Department of Public Expenditure and Reform for the two posts.

Whose call is it to carry out the reorganisation?

Mr. Dean Sullivan

Once the authority and agreement are there from our sponsoring Department, the Department of Health, it is within the organisation's gift to best organise itself, within the confines it needs to work within.

That has been well trailed back to some of the discussions earlier on.

Ultimately someone must make the final decision that the organisation is going to go ahead and do this. Was there a vote taken by the directors or was it just Tony O'Brien on his own? Who makes that final decision to sign off on it?

Mr. Dean Sullivan

I do not know the answer but I can check. I imagine it was a directorate decision.

Mr. Pat Healy

The director general at the time brought that to the directorate. It was communicated to the Department and consultation and discussions were had with the Department. We mentioned that earlier as well.

With a new director general coming in, are there going to be more changes? Is he or she going to adopt and accept this new structure or will there be more changes?

Mr. Dean Sullivan

I see no prospect that the split we have talked about in terms of getting a bit of clarity around the strategy and planning to sync more operations and then the clinical side of things will change, but all this is as we discussed earlier. To be fair to the previous director general, he had sought for some time to develop the idea of having a properly constituted board in place, that the executives would be accountable-----

Mr. Sullivan does not know if this new director is going to make any change.

Mr. Dean Sullivan

What I said was that my expectation is that there would be no logical reason for them to change what is now being put in place but they may have a different view.

Logic does not always win, though, does it?

Mr. Dean Sullivan

Unfortunately not.

I am going to summarise exactly what we have asked the witnesses to do today, if that is alright. Deputy Neville asked-----

Before we summarise, I have had a look at the CAMHS videos that were discussed. I have not been able to hear them but the graphics and so on look quite good. There should be a campaign plan put together to market them because the views are very low. I know they only went up in the last three weeks-----

Mr. Jim Ryan

Three days.

Only in the last three days in the case of some of them. There should be a marketing campaign to start pushing that out. The videos should also be subtitled for people who might be hearing impaired.

Thank you, Deputy. Deputy Neville was looking for an organisational structure chart, and I added that it should include numbers in each section. We will send the witnesses an official request for this. Could they also add the figures for clinical and non-clinical staff out of the whole of the mental health services, sub-divided into the numbers working in HR, finance and some of the other divisions?

The next thing was how appointments were made in the new structure, excluding you, Mr. O'Sullivan, how Ms O'Connor and Mr. Ryan were appointed - the witnesses have said they will provide us with the information on how the appointments were made, how they were advertised, whether there were salary increases, etc.

The next request was for a table showing how mental health funding as a percentage of total health funding has changed in recent years. A note on the clinical care pathway for young people was requested as was a comprehensive report or note on the IT project on budgeting. I think that is it.

Mr. Dean Sullivan

To clarify, the IT issue was for Deputy Neville around the finance system specifically. It was for a comprehensive note on the introduction of the finance system that will give greater clarity on some of that.

Yes. Deputy Neville also asked how the money from development funds went into the improvement of existing services. We will have a very clear request going out formally to the witnesses. I thank them for attending today, especially given the length of time they have been here, and thank them for the very useful information they have given us. It will greatly assist the committee.

The joint committee adjourned at 4.05 p.m. until 1.30 p.m. on Wednesday, 23 May 2018.