Mental Health Services in Prisons and Detention Centres: Discussion

I welcome Ms Deirdre Malone, executive director, and Ms Michelle Martyn from the Irish Penal Reform Trust, IPRT; Mr. Michael Donnellan, director general and Mr. Enda Kelly, national operational nurse manager, Irish Prison Service; Professor Harry Kennedy, clinical director, and Mr. Peter Byrne, peer educator service with the national forensic mental health service at the Central Mental Hospital, CMH; Mr. Pat Bergin, campus director, and Mr. Damien Hernon, deputy director, Oberstown Children Detention Campus. On behalf of the committee I thank the witnesses for their attendance. They will be invited to make a brief opening statement, which will be followed by a question and answer session.

I draw the witnesses' attention to the fact that, by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to 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 asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.

I remind members and witnesses to turn off their mobile phones or switch them to flight mode because it causes havoc with recording. I ask members and witnesses to place their mobile phones on the floor.

I invite Ms Deirdre Malone to make her opening statement.

Ms Deirdre Malone

IPRT welcomes the invitation to make a submission on mental health and we commend the committee for its initiative in choosing to focus on the state of psychiatric services in Ireland’s prisons and detention centres. IPRT views gaps in mental health provision as one symptom of wider social exclusion and is intrinsically linked to criminal justice and penal policy. The committee can refer to the briefing provided for the detailed sources supporting our key points but during this oral hearing, we will highlight those which we consider most pertinent.

The level of mental ill-health difficulty in the Irish penal system is overwhelming in both its scale and complexity, and the challenges are growing daily. Walking through our prisons, that current reality is evident on every landing and every wing and ranges from the severely psychiatrically unwell to those experiencing anxiety and depression. This should come as no surprise. The experiences which precede incarceration are often marked by multiple vulnerabilities, including adversity, trauma, abuse, violence, addiction, and experiences of care, poverty and homelessness. The experience of prison itself such as overcrowding, enforced solitude, lack of privacy, lack of meaningful activity, violence, isolation, insecurity about future prospects and broken family relationships compounds those problems. It can actively exacerbate existing mental health issues, heighten vulnerability and increase the risk of self-harm and suicide. Why then does the State continue to warehouse those with the most complex needs in prisons that of themselves both cause and exacerbate existing mental illness?

A decade ago, 3% of the prison population had a severe, enduring and disabling mental illness such as schizophrenia. Since 2015, this has more than doubled to 7% to 8% of the prison population. A 2005 study on the prevalence of mental illness among prisoners in Ireland showed that for sentenced prisoners taking into account all mental illnesses, the rate for men was 27% and for women almost twice that level, at 60%. More recently, those working on the ground report to the IPRT that even higher overall levels of need are present and, within that, there are increasing complexities and multiple vulnerabilities. In addition, our prison population is rising. After a period of relative stability, more and more of those convicted have been sentenced to prison and our female prisons are consistently overcrowded. At the same time, both the Central Mental Hospital and the Irish Prison Service face difficulty recruiting sufficient staff to meet the overwhelming need.

In 2015 the European Committee for the Prevention of Torture, CPT, said: "Irish prisons continue to detain persons with psychiatric disorders too severe to be properly cared for in a prison setting." The committee recommended that Irish authorities enhance the availability of beds in psychiatric care facilities for acute mentally unwell prisoners. It particularly queried the level of psychiatric care provided at Castlerea Prison and the long waiting list for the CMH. Similar concerns were voiced in 2011, yet seven years later there is still a lengthy waiting list for the CMH, there is no psychiatrist at Castlerea Prison and we still have the lowest ratio of psychiatric beds in Europe. The CPT will return to Ireland next year to inspect our prisons. After this hearing has concluded and after the Oireachtas committee report is published, will the committee witness the same indefensible state of affairs it saw three years ago? I ask this committee to consider in the coming years what will have changed.

While the focus of this hearing is on psychiatric care, the terms of reference of this committee is to look at the future of mental health broadly in Ireland. A properly resourced mental healthcare profession in the community at the earliest point and especially for children will reduce the number of those coming into contact with adult criminal justice system. Researchers and clinicians agree that early mental health assessment is required in order to prevent escalation of need.

On 14 May, the Irish Examiner reported that almost 2,700 children are currently on the list for mental health appointments with 368 having waited over 12 months. This has been described as a service reaching crisis point. Failing to resource the child and adolescent mental health services, CAMHS, increases the number who end up in our penal system. In Oberstown in April of this year, there were concerns for 23 out of 50 young people in respect of their mental health, 13 had a history of self-harm and 32 had been misusing alcohol and-or drugs prior to detention.

Mental health care provision in the community is also especially relevant to continuity of care on release. While prison-based medical personnel make great efforts to create these links, they report there is effectively no adult psychology service available to which to refer in the community.

We note that the committee has been specifically tasked with examining the "significant challenges in the recruitment and retention of skilled personnel". The current ratio of senior psychologists to prisoners is in the region of 1:260 but should be in the region of approximately 1:150. A Vision for Change recommended that "[w]here mental health services are delivered in the context of prison, they should be person-centred, recovery-oriented and based on evolved and integrated plans”. It is simply not possible to deliver that level of service to all who need it in a situation where prisons cannot recruit a sufficient number of psychologists.

High support units provide expert support to prisoners who are in an acutely disturbed phase of mental illness as a short-term intervention within the prison. There are currently only two in operation but it has been recommended that one is required in all prisons.

The number of secure forensic beds for the mentally ill is currently the lowest in Europe at two per 100,000. As of April 2018, 26 prisoners were awaiting transfer to the CMH from prison. There are no published data on how long each individual prisoner waits to be transferred but it appears that many lower on the waiting list for a transfer are unlikely to be transferred due to the lack of available spaces.

Twelve years ago, A Vision for Change recommended that the CMH “be replaced or remodelled to allow it to provide care and treatment in a modern, up to date humane setting" and to maximise capacity. With the opening of the new facility at Portrane, the psychologist-prisoner ratio of 2:100,000 is likely to only reduce to 3.5:100,000, which is still well below the European average. The alarming growth in the prison population during the past six months makes this situation even more concerning.

The Report of the Commission of Investigation into the Death of Gary Douch was published in May 2014 and found at that time there was "reckless disregard for the health and safety" of prisoners and staff alike in a decision taken to transfer a prisoner who had been assessed as "acutely psychotic" to Mountjoy Prison. At that, I commented that "if there can be any positive legacy at all from this tragedy then it should be that concrete and effective changes will be swiftly introduced". That report contained 35 recommendations specifically in the area of mental healthcare and treatment in Irish prisons. Four years later, while an interdepartmental group was set up in 2012, it is unclear to what extent, if any, those responsible for implementation have taken action.

In April 2018, more than 500 prisoners in our prisons were on a restricted regime with the majority of those prisoners held on 21-hour lock up. This practice is detrimental to any prisoner's mental health. The European Committee for the Prevention of Torture, CPT, has recommended that the maximum period an individual spends in solitary confinement is 15 days and beyond that point the psychological damage may become irreversible. Similarly, suicides are over-represented among the prison population.

In brief, the human reality of the combination of failures to provide sufficient mental health services at an early point, coupled with the failure to provide sufficient spaces in our acute and psychiatric facilities along with tough-on-crime rhetoric, results in: mentally unwell women in the Dóchas Centre sharing cells; prison staff trying to cope with high numbers in unsuitable facilities; and Ireland contemplating a bleak future in which nothing has changed and nothing changes.

In our view there are many things that can be done to start to improve the situation, which we have set out in our briefing document. In short, before prison, we propose: more investment and use of prevention and early intervention supports; urgently addressing the current waiting list for children and young people; the development of diversion schemes in courts and police stations; and in respect of CMH to ensure sufficient spaces and provide sufficient staff to deal with those with severe mental illness. In prison, we propose: the prohibition of solitary confinement should be prohibited and access to justice for those in solitary confinement; implementation of the recommendations of the Report of the Commission of Investigation into the Death of Gary Douch; the provision of enough prison psychologists to reach an appropriate ratio; ensuring all prisons have a high support unit; ensuring single-cell accommodation for every prisoner; and to make mental health training available for every prison staff member. After prison, we propose the making of links to the community, linking with psychology supports or to make them available if they do not exist.

We urge the committee to do everything that is within its power to make an impact on the ground for those who are currently suffering in our prisons and detention schools and those staff and professionals who are trying to cope with an untenable situation.

Thank you, Ms Malone. It has been quite difficult listening to your statement. I call Mr. Michael Donnellan.

Mr. Michael Donnellan

I thank the Chair and the members for inviting me to appear before the committee. I am joined by my colleague, Mr. Enda Kelly, a national operational nurse manager. I hope the information we and the other representatives provide will assist in viewing solutions to help prisoners who are suffering from a mental illness.

The management of persons committed to prison presenting with severe and enduring mental illness is one of the major challenges to effective healthcare in prisons. There is evidence from the national forensic mental health service team, which is supported by our healthcare staff, of an increasing number of prisoners requiring treatment for mental health issues within our prisons.

On 18 May, we had just under 4,000 prisoners in custody. Of that number, 323 were on the caseload of the national forensic team and they were deemed to be suffering from severe mental illness. Behind that group, there are another several hundred prisoners.

The national forensic mental health team at the CMH provides an in-service to us. It also provides a court diversion service to the Irish Prison Service. This includes consultant forensic psychiatrists, non-consultant hospital doctors, community forensic psychiatric nurses, social workers and other staff. The standards of care for the provision of services to prisoners with mental health difficulties include assessment, prison in-reach and ongoing treatment within the prison setting or escalation to the forensic team at the CMH. The prison in-reach arrangements provided by the national forensic mental health team are an excellent example of partnership working and provide an invaluable service to a significant body of prisoners who suffer from a severe mental disorder. The in-reach team to prisons has expanded in recent years with additional consultants, nursing and social work resources. Approval was granted by the HSE in 2016 to provide consultant-led mental health services to Limerick, Cork and Castlerea prisons, which was a most welcome development. However, it has not been possible for the HSE to recruit consultant forensic psychiatrists for those three prisons.

Significant problems have been experienced in Castlerea Prison specifically as the national forensic mental health service in-reach to that prison was discontinued in April. Regrettably, that has resulted in the necessity to transfer very ill prisoners from Castlerea to a Dublin prison for assessment, which is not only problematic from a logistical perspective but it is less than ideal for those suffering from a major mental illness.

The Irish prison psychology service also plays a key role in helping to deal with mental wellness and prisoners to cope with imprisonment. The psychology service consists of the head of psychology, eight senior psychologists, 11 staff grades and nine assistant psychologists. They undertake a range of mental health supports, including interventions matched to the severity of the presentation. Interventions include self-help, psychoeducational workshops and individual and group-based therapies.

There is an increased risk of morbidity and mortality when mentally ill prisoners come to the end of their sentence. To help manage that increased risk, a pre-release planning programme with HSE social workers was established in Mountjoy Prison. This pre-release planning intervention has shown that collaboration between the national forensic team, the Prison Service and community-based supports greatly improves sentence-planning for mentally ill people and 91% were accepted by community mental health teams on return from Mountjoy Prison.

It shows something can work. However, notwithstanding the in-reach and psychology services available, and the positive examples of collaborative working, the fact remains that imprisonment is inappropriate for people with severe and enduring mental illness as prisons are not therapeutic environments.

With regard to admission to the CMH, a waiting list is operated by the national forensic mental health team and is reviewed weekly. Over the last ten years, the waiting list has fluctuated from between five and 30 prisoners at any one time. It should be noted that all prisoners placed on the waiting list have been clinically assessed as warranting admission to the CMH, which is a tertiary care facility. Today in Cloverhill Prison there are in excess of 15 prisoners deemed to require admission to the Central Mental Hospital. Overall, there are 30 people on the waiting list for the Central Mental Hospital facility. The continued detention of these individuals without proper access to the services and inputs of an appropriate clinical team exacerbates and increases the morbidity of the prisoners concerned. Leaving people untreated increases risk. The absence of appropriate access to admission beds for all prisoners who have been deemed to require such admission also exacerbates the risk to our staff in managing prisoners with serious mental health issues in a prison setting.

The Irish Prison Service has invested heavily in training and education for staff in dealing with individuals with mental health issues. Notwithstanding the clinical expertise of Irish Prison Service staff, supported by the in-reach staff, considerable clinical, individual and corporate risks remain. The disproportionate draw on resources to facilitate, protect and afford the best quality of life for prisoners with severe mental illness in custody means that others' services are disadvantaged and restricted. It has to be remarked that the input of prison officers is the mainstay of providing the best quality of life possible for such prisoners in custody, and I wish to specifically acknowledge the work done by our healthcare and discipline staff who are managing this level of difficulty in as humane and compassionate a way as possible. However, with the best will in the world a prison is not, and should never be, a suitable or appropriate clinical environment.

I was so taken by what you were saying, Mr. Donnellan, that I am almost unprepared for the next person. I call on Professor Kennedy.

Professor Harry Kennedy

I thank the committee for inviting us to this meeting. I have brought two colleagues with me: Mr. Peter Byrne, who is peer educator from the service reform fund and attached to the national forensic mental health service, and Mrs. Pauline Gill, who is general manager of the national forensic mental health service. I will talk about problems, causes and solutions taking the headings of the committee's terms of reference.

With regard to waiting lists for transfer from prison to the Central Mental Hospital, currently there are 28 on the waiting list and there are 323 on the caseload of the in-reach teams we provide to the Irish Prison Service. All of the people on the waiting list are urgent. All of them are severely mentally ill and should not be in prison. They have been on the waiting list for months and this is entirely unacceptable by any clinical standards. When we surveyed the numbers with severe mental illnesses in the prison population over ten years ago, we found there was a need then for approximately 350 secure forensic beds for Ireland. Matters have probably worsened since, although we have taken every alternative strategy as far as possible. I will list those as we proceed. We have tried to manage with minimal resources compared to other countries, and I can tell the committee what the averages in other countries are. Matters are managed only because the Irish Prison Service does not complete certificates for those who should be admitted until we have a bed available. One of the problems for all of us is that we manage to cope in increasingly difficult situations. Ultimately, that is not a great thing.

As clinical director I have statutory obligations under the Criminal Law (Insanity) Act. I am increasingly unable to meet my statutory obligation to admit those found not guilty by reason of insanity in the courts. Again, we cope by asking the courts to put off sentencing, for example. We have published the results of participatory action research showing how a systematic screening of people on reception in prison identifies those in need of psychiatric care. We have shown that we can identify those who need treatment and individual care and treatment plans. Most can be diverted back to community mental health services. We have now set up a model service, which is copied in other countries. We originally modelled it on the Australian system and now other people come to visit us. However, there is an irreducible number, those who are on our waiting list and those on our caseload, who cannot be managed in community mental health services or approved centres around the country. Those who are too dangerous to others because of their severe mental illness require treatment in conditions of therapeutic security.

The national forensic mental health service currently has 93 beds for adults in need of treatment in conditions of therapeutic security. That is two per 100,000 of the population of Ireland. This has not changed for many years. Comparable countries have between five and 14 secure forensic beds per 100,000. The Netherlands is at the upper end of that range. We will move to 130 adult medium and high secure forensic beds in Portrane in 2020, with an additional 30 intensive care rehabilitation unit, ICRU, beds which will now have to serve the entire country. That will give us 3.4 adult secure forensic beds per 100,000. Comparing like with like, most developed countries have between five and 14. We will also open ten forensic secure child and adolescent mental health beds on the Portrane campus, but obviously not within the adult campus. The new hospital will not bring Ireland up to international average resource levels.

On the need to meet long-term needs, because of the lack of a national plan to meet the needs of those requiring longer-term, slow-stream care, treatment, rehabilitation and quality of life in secure forensic hospital settings, and because of the continuous growth of this group, we think it will be necessary to plan for the introduction of designated centres, as a matter of desperation, in prisons. I entirely agree with what Mr. Donnellan has said. Looking at the global situation, this has already happened in the Netherlands, Finland and other progressive European countries even when much better resourced than we are. The Netherlands has the most forensic beds in the community and it is now opening designated centres in the prisons. We might discuss the root cause of this if there is time. There will also be a need for longer-term secure psychiatric beds within five years of the opening of the new Central Mental Hospital in Portrane. We can already foresee that the new hospital will not be enough and we would like to start planning the next step now.

According to the committee's terms of reference there was a consensus that the 2006 policy, A Vision for Change, charts the best way forward for mental health services. A consensus can be specific to its time or it can fail to address some important areas. Sometimes it can be wrong. A Vision for Change is now out of date because it could not take account of modern knowledge regarding, for example, at-risk states in the young and, because of its era, it could not take account of modern evidence for enduring neurocognitive impairment occurring during the prodromal onset stage of schizophrenia and other severe, enduring and disabling mental illnesses. For a proportion of patients these illnesses are now better conceptualised as developmental disorders and enduring disabilities.

A Vision for Change did not address the need for general adult psychiatric admission beds in an epidemiologically appropriate way. From EUROSTAT we know that, typically, other countries have between 40 and 60 general adult beds per 100,000 while A Vision for Change recommended 17. We managed to get it down to 20 before a halt was called. It also did not seek to examine international best practice regarding the use of such resources. A Vision for Change did not address the need for local psychiatric intensive care units, for example, as part of general adult psychiatry. Typically, other countries would have three such beds per 100,000. We have hardly any. The plan for four intensive care rehabilitation units in A Vision for Change was a compromise between the need for approximately 350 secure forensic beds, including secure slow-stream rehabilitation beds, and the acute general adult psychiatric local intensive care beds, PICUs.

In the event, neither has been prioritised. A Vision for Change recommended that general adult psychiatry should reduce to 17 beds per 100,000 based on an ideological and frankly faith-based belief that acute, sub-acute and rehabilitation treatment for severe mental illness could be done in the community. This missed evidence that even countries with well-developed community services still have 40 to 60 beds per 100,000 for general adult psychiatry. EUROSTAT shows us these data. Countries such as the Netherlands and Germany and the Scandinavian states, which provide the most progressive community services, provide choice. They also have inpatient services. No research has shown that community services work as an exclusive option. In practice, in many countries, including Ireland, the only way to obtain treatment for more than a week or two and longer-term intensive care packages in the community is to access these through the criminal courts.

Eleven years after its publication, A Vision for Change is not yet fully implemented. All those aspects of A Vision for Change that removed or diverted resources for mental health services for severe mental health were implemented. Those that transferred resources into the planned community services were not fully implemented when they cost money - revenue - or manpower. Resources - revenue and manpower - have been lost to services for people with severe and enduring mental illness. I suggest that now is the time for an entirely new document, not a revision of an old document.

The joint committee might want to try to achieve agreement on the best rational, scientific and clinical evidence for effective services that achieve human rights, including rights to dignity, rights to health and rights for disabled people, including quality of life, for people with severe mental illnesses, particularly those with enduring impairments of functional mental capacities due to mental illnesses or intellectual and developmental disorders, for people in need of long-term care and treatment in conditions of therapeutic safety and security due to the danger they present to others, and for people who do not present a danger to others. There should be some effort to engage and develop the health and justice interdepartmental and inter-agency consensus about the relationship between individual freedoms and the protection of others. My colleagues - psychiatrists and other mental health professionals who work closely within the criminal justice system - and I are continually concerned about the exercise of bail for those who are a danger to themselves. There is a lot of evidence that suicide rates are high among those bailed - higher, curiously enough, than among those remanded in custody. There is also a concern about the exercise of bail for those who are a danger to others.

Regarding the current integration of delivery of mental health services in Ireland, there are problems with integration of services due to the emphasis on local delegation of responsibilities without delegation of competencies. The failure to develop PICUs locally is the most obvious of many examples along with the rejection of those who become homeless, which is a continuing problem for us at the transition between criminal justice and mental health, between custody and the community. The rejection of those who become homeless is an obvious failure of the catchment area system and the substantial lack of beds and community mental health teams that could be corrected at least in part by empowering central direction and, if necessary, by legislating for central directors of services.

Many other states the size of Ireland have so-called clinical chiefs or heads of psychiatry who are the ultimate line managers of all psychiatrists and can direct colleagues to accept patients who are otherwise unable to obtain services. Ireland urgently needs an office of chief psychiatrist, comparable to those in states in Australia, with the power to direct that no one is deprived of rights of access to mental health services and, where necessary, to drive resource allocation. This would include an oversight of evidence-based and effective services of equal quality, accessible equally to all, around the life cycle. The office of chief psychiatrist would integrate heads of all disciplines and ensure co-ordinated manpower planning and multi-annual planning of service delivery, all things that are missing at the moment.

The office of chief psychiatrist should be independent of the Mental Health Commission and should have the ability to exercise executive power. It should not be merely an advisory position. There are such advisory positions, which have a role in their own right. This would solve the problem of preventing rejection and ensuring provision of mental health and substance misuse services for those leaving prison, an important group among the homeless. Co-operation with primary care, disability and welfare services would be an added task since this does not work as well as it ought to.

The commissioning of regional and national tier 3 and tier 4 services should also be under the central direction of an office of a chief psychiatrist which should include chiefs of other clinical disciplines and should be supported by managers. This office of chief psychiatrist should also be responsible for the commissioning of service-related research, development, teaching and training, which is a virtuous cycle that is essential for excellent services. This office should not be vulnerable to being starved of necessary resources. It could be said that the executive clinical director experiment was starved in that way.

I would suggest that a central office is needed. To achieve the availability, accessibility and alignment of services and supports to ensure the integration and seamless provision of services to children, adolescents and young adults during life cycle transitions and the transition from working age adults to older adults, the appropriate solution is a national office of chief psychiatrist with the power to direct local service providers, including consultant-led community mental health teams.

Regarding the need to develop prevention and early intervention services further, I must sound a note of caution with regard to prevention. The evidence is tenuous that severe mental illnesses and mental disabilities such as schizophrenia, bipolar affective disorder, autism and intellectual disabilities can be prevented. There is little evidence that any programme can prevent schizophrenia, autism or other disabling severe mental illnesses, although these affect about 1% of the population. There is better evidence that early intervention can reduce long-term disability, although even this requires further research and development specific to an Irish context. To be effective, this requires a shift to screening models from help-seeking models where a person is expected to present themselves to their GP or where their family might do that and it is hoped the person will escalate through the system to find what they need. In effect, this is what we do in our in-reach systems in the criminal justice system. We screen on reception. We are introducing the same in the youth justice service. There is also a requirement to set quality standards for "treatment as usual" and a rolling programme of randomised controlled trials of how to improve treatment as usual at national level. There is no consistency in what a person would get as treatment depending on where he or she happens to be.

Regarding at-risk mental states, in St. Patrick's Institution, which is now closed and which provided for those aged 16 to 21, we found through screening that 23% of young people on reception met clinical criteria for an at-risk mental state, which carries about a 15% chance of going on to develop a severe mental illness. These were strongly associated with poly-substance misuse, which occurred in the great majority of young people detained. We are now finding much the same in Oberstown Children Detention Campus, allowing for the younger age group. It is not quite so common in people who are younger. We have not been able to recommence screening there, however, partly due to difficulties recruiting a full team. I will talk about the system of recruiting panels compared with bespoke recruitment.

Regarding suicide and unnatural deaths in adult prisons, the suicide rate in prisoners is now lower than it was 20 years ago when it was the main impetus. We believe this is the direct result of the introduction of screening on committal and psychiatric in-reach and court liaison services, PICLS. PICLS is, again, picked as a model for other countries. In our most recent survey of coroners' verdicts, we found that unnatural deaths, including suicides, were strongly associated with the deceased having illicit intoxicants in the blood at the time of death.

We have introduced a pre-release planning programme, about which Mr. Donnellan spoke. We have now piloted a service for arranging aftercare packages for mentally ill prisoners on release from custody. The pilot at Mountjoy Prison has shown the value of this scheme.

We have taken what we can do in the prisons and in the community as far as we can. We have high-support units in Cloverhill and Mountjoy. We have screening systems on reception in almost all of the prisons. We have systems to divert through the courts those who can be safely cared for in the community or through local services. We have 323 people on our prisons case load today. This includes those who are sentenced and those who are on remand. We cannot accommodate those who are too ill for prison and we cannot admit them either.

A vital way to improve recruitment is to have a culture of excellence. The HSE must urgently shift towards a culture of clinical excellence. Excellence is inseparable from the virtuous circle of research, development, teaching and training. Only centres of excellence should be empowered to train postgraduate mental healthcare professionals. Ireland should be self-sufficient in all mental health professions. Manpower planning to date is difficult to understand. We struggle to attract the best trainees - or sufficient numbers of trainees - because the mental health services do not enjoy a reputation for excellence, unfortunately. I say that as someone who is within those services. The mental health services do not have a positive image as valuing health and welfare outcomes for patients. A part of the problem is that many trainees go abroad to broaden experience, which is a good thing, and are unwilling to return to work in services that do not provide resources or cultivate excellence. They are unwilling to return to work in services that do not provide resources to keep up with modern practice and are subject to periodic serious impairments in quality and staffing during economic recessions. Specialist niche services such as the National Forensic Mental Health Service should be able to conduct bespoke specialist recruitment. When we were able to do so, we were always oversubscribed. The HSE's generic panel system has been a disadvantage to us.

I suggest that the joint committee should make explicit recommendations based on current international standards and should support those who are working continuously to keep these standards up to date. These standards should be grounded in the evidence of clinical science and not merely on good ideas. Good ideas are never a guarantee of success. Expertise has a technical definition. Experts may be contributory, interactive or experts by experience. All of these are valuable, but they are different. A Vision for Change put itself forward as the report of an expert panel. I think it is important to know properly what expertise is. Only contributory experts can be held responsible for a standard of competence in their evidence. Interactive experts are people like managers, lawyers and journalists who learn expertise by talking to the contributory experts who are responsible. There is a complete divorce between responsibility and the exercise of any sort of influence. There is every chance that the mistakes that have been made in the past will be made again. The committee should have access to expert advisers who have contributory expertise. Currently, there are few if any expert advisers in the Department of Health concerning psychiatry or any of the clinical disciplines. The HSE has advisers on clinical programmes, but no directors. The committee should have regard to the meaning of expertise.

I thank Professor Kennedy. I ask Mr. Pat Bergin, who is the director of the Oberstown Children Detention Campus, to make his statement.

Mr. Pat Bergin

I am pleased to report on the progress we are making at Oberstown in delivering mental health services to young people who are sent to us by the courts. My role as director is to manage the campus and ensure we provide the highest standard of care to young people in a safe environment, thereby fulfilling the requirements of the Children Act 2001. Oberstown, which is the national detention facility for the care of young people referred to us by the courts on remand or detention orders, is a safe and secure environment for young people. We place a key focus on addressing offending behaviour and preparing the young people in question for their return to their families and communities. All of that is part of the process. The Oberstown campus is a modern facility with new buildings and services. Our programmes are based on best practice for young people who offend.

Young people who come to Oberstown have generally experienced significant adversity and disadvantage across their lives. They are usually between the ages of 15 and 17, male and have had significant association with the care system. We undertook a review of the characteristics of young people detained on the campus in early 2017. We are in the process of completing a similar exercise for 2018, with a particular focus on the challenges. The outcome of the 2017 exercise affirmed that many of the young people who are placed with us struggle with poor experiences in education, suffer from mental health problems and addiction, and have often experienced trauma or loss. Our young people have been through many of the State services and supports, often unsuccessfully. They present to us with challenging behaviours and complex unmet needs.

The facility at Oberstown can accommodate 54 young people at any one time. Oberstown currently has a daily population of 50, which is slightly under capacity. One third of the young people in Oberstown are on remand orders. Since April 2017, young people under the age of 18 are no longer sent to adult prisons and instead come to us. Over the past couple of years, the board of management has approved a strategic plan for Oberstown, the first objective of which is to provide the best possible care for young people. We have identified a number of key actions, including the development of multi-agency and specialist support to deliver effective assessment, clinical and therapeutic services. We have developed and are implementing a strategy of participation with young people through ongoing consultation with them about their care and ongoing needs. This involves hearing the voice of young people. A range of developments and policies have been approved by the board. They focus on areas like care, health and well-being, dignity and respect, anti-bullying, complaints, safeguarding, single separation and medication management. These policies and related ones provide support in the area of behaviour management and inform the procedures to be undertaken by staff in the care of young people. There are a range of services on site at Oberstown to meet the needs of young people. The campus has an approved framework based on the Children Act 2001, which sets out the areas we need to address, including care, education, health and well-being, offending behaviour and preparation for release.

The assessment consultation and therapy service, which operates as part of the Tusla family agency service, has a team based in Oberstown. The members of the team, who are professionals in areas like psychology, speech and language, substance misuse and social work, work in conjunction with our residential social care workers and nursing staff to provide an integrated programme for young people. This service was established in 2013 on foot of the recommendations on the 2009 report of the Commission to Inquire into Child Abuse. Two specific actions set out in the report pertained to young people in special care and detention. The report called on the HSE, in consultation with the Irish youth justice service, to develop a national multidisciplinary team for children in special care and detention. It also called on the HSE to review the need for and establish resourced multidisciplinary assessment services for children and young people at risk. The assessment consultation and therapy service at Oberstown receives referrals and assesses the needs of young people following a multidisciplinary team meeting. A formal assessment tool is used by our staff in Oberstown as part of a screening process to determine the mental health needs of young people. Direct assessments are also undertaken by the assessment consultation and therapy service team. Following consultation with parents, care staff and the other services involved with the young person, it is determined what, if any, interventions are required. Areas of focus include responding to needs of a young person due to developmental trauma and disruptive care histories, emotional regulation and general mental health and well-being. The team engages directly with the campus placement planning process, which looks at each young person's individual need in the areas of care, education, health and offending behaviour.

The HSE provides psychiatric services through the Central Mental Hospital, which operates the national forensic mental health service. We share with that service a goal of providing a high standard of care and treatment to young people with a mental disorder. This team, which is on site each week, works as part of a multidisciplinary team to assess and respond to specific mental health concerns as necessary. A referral process is in place. Consideration is given to these referrals weekly or in some circumstances immediately as necessary. The multidisciplinary team addresses the needs of young people. The staff in Oberstown provide support to young people on an ongoing basis.

Within the campus, we have 110 trained and experienced residential social care workers and 50 night supervising officers who work directly with our young people. We have a medical team on site, which consists of three nurses and a social care worker. We have a visiting GP who attends the campus three days a week and engages with the medical team, the HSE and other clinicians in meeting specific identified needs. Thirty-one members of our staff have been trained in or are in the process of completing STORM training, a recognised self-harm mitigation model developed at the University of Manchester. It provides skills-based training in risk assessment and safety planning to our staff. It also supports staff to determine what to do after a serious incident has occurred. We operate and provide substance misuse programmes and we access support from the assessment consultation therapy service, ACTS, and community programmes. In June and July of this year, we have organised 16 substance misuse relapse prevention programmes on the campus, which are based on the adolescent community reinforcement approach. A community-based service is providing these programmes as part of our summer activities and education schedule. In September 2017, we appointed a young persons programme manager to support the identification of suitable programmes and the implementation of a programme of training and engagement. We have been successful in the delivery of many of these in the past year and a half.

The challenges facing young people detained in Oberstown are complex. For many young people there are known risks and the approach of Oberstown is to keep young people safe especially during times when young people do not know how to keep themselves safe. Our engagement and approach with young people is individual-based and is informed by professionals on the needs of each young person. We continue to review and improve our approach to the health and well-being of young people placed in Oberstown.

I will explain what will happen now. There will be questions from the members. Each member will have seven minutes to ask questions. They will choose whom they direct their questions to. Witnesses should try to make their answers as succinct as possible. We will go first to Deputy Tom Neville.

I thank the witnesses for coming in today. I welcome their submissions. They made a number of testimonies. We will touch on different issues. My first question is to Ms Malone. She mentioned links back to the community after prison. Will she flesh out her ideas on that? What does she feel could work?

Professor Kennedy mentioned A Vision for Change and how he felt it was out of date. He said he felt a new A Vision for Change was required as opposed to a revision of the old one. Has he been in consultation with the revision group or groups? Has any consultation taken place? Has there been an initiation of communication or anything like that? He spoke about contributory experts as opposed to expert advisers. Could he provide more clarification on that? He said the HSE was working with more expert advisers as opposed to direct contributory experts. What would be the best formula for how that would be implemented or changed or how it could be done within the HSE? He spoke about local adult intensive care psychiatric units and the provision for those. Professor Kennedy's contribution was quite lengthy. He mentioned that parts of A Vision for Change regarding severe mental health conditions had been implemented. I want clarification on that. Is what Professor Kennedy said that intensive care psychiatric units should be more community based? Could I have clarification on that?

I thank the Deputy. The question about consultation on A Vision for Change was an excellent one. Will Ms Malone answer first?

Ms Deirdre Malone

It might be helpful to distinguish two things which I think are quite important. Professor Kennedy addresses severe mental illness for people who require treatments and conditions of therapeutic security. He is the expert on that in terms of psychiatric treatment. In preparation for the hearing I spoke to a number of staff who work in the medical area of the prisons. They tell me that an issue arises for those who manage to access, for example, an addiction counsellor or psychology services within a prison, for example in the Dóchas Centre or any other centre. It is particularly an issue for women because women in prison present with enormously complex life histories and experiences. When those women access services or make progress while they are within the criminal justice system and are lucky enough to have those opportunities the frustration being expressed is that there is not an equivalent service in the community so the person who has been working with that woman or man cannot make the link to a designated person in the community who will continue to provide a similar service for a period of time. We work in penal policy and criminal justice policy. We are not mental health experts but we are interested in listening particularly to those who work on the ground with those who are incarcerated and we are interested in considering the problems and barriers they face and what they see is working. It may assist in answering the Deputy's question. That is what they are telling me about. There is a dearth of services within the community for women or men who have made some progress with their mental health difficulty and wish to continue to do so on release but there are not always services there to catch them on release.

Professor Harry Kennedy

I thank the Deputy for his question. We have not heard anything from the committee the Deputy mentioned. We hope we do eventually. His next question was about contributory expertise.

Will Professor Kennedy explain it more for people who do not have medical expertise?

Professor Harry Kennedy

There is a terrific book on this which I referenced in my submission. There are three kinds of expertise. There are experts by experience - my colleague here is an example - who have an intuitive understanding of the lived experience of a topic, which is a very important aspect. There are interactive experts, people who talk to contributory experts all the time and come to understand the vocabulary and can be quite fluent in that vocabulary. Examples of this type are journalists, lawyers and pure managers. Contributory experts are a bit like master craftsmen. They are not only at the top of their skill and ability through training and long expertise but they can expand their subject a bit. Senior mental health professionals in all the disciplines are the contributory experts who know how to do something and how to make it better. Managers talk to them every day and absorb from them but will lose their expertise the minute they stop talking to contributory experts. The HSE, like many health services, is run by these interactive experts. It is not run by the contributory experts. That is a problem.

I thank Professor Kennedy.

Professor Harry Kennedy

The Deputy also asked about psychiatric intensive care units, PICUs. It is not enough to say that we need 17 general adult psychiatric beds per 100,000, which is what A Vision for Change said - other countries have 40 to 60, or even 80; we need to specify different types of beds for different purposes. There are admission beds, rehab beds and specialist beds for special things like eating disorders. Crucial in there is local low secure acute units, psychiatric intensive care units. There should be one for every 300,000 of the population, which is about 12 beds, or roughly three per 100,000. Some would say the number is 3.5. I only know of one in the entire country and that is the Phoenix unit.

I am playing devil's advocate by asking the following question. If the contributory experts do what Professor Kennedy says they should be doing would that not be taking them away from their core function of treating patients, if they spend all their time managing and directing?

Professor Harry Kennedy

What I was talking about was an office of chief psychiatrist who would be a contributory expert who would have some way of co-ordinating, directing and ensuring consistency among services generally.

For example, if someone is homeless and is rejected by every service because services only operate for people with addresses, one needs someone like a director of psychiatry to break through that. There must be an ultimate line manager. That person would also have the level of epidemiological knowledge that is normal for me. I am able to tell the committee about these numbers because it is my expertise. There is a need for that.

I thank all of the contributors. Their presentations were among the best we have received. They were fantastic. There is a great deal of information there for us to work on. I start with Mr. Donnellan. I am acutely concerned about Castlerea. Mr. Donnellan said the services there had been withdrawn. What impact is this having on the prisoners and staff and what exactly was lost in April? What exactly was discontinued?

Mr. Michael Donnellan

Castlerea takes many prisoners from the west of Ireland and the north west. It has a population of 300, 30% of whom are Irish Travellers. It has a very mixed population with high needs. I said in my opening statement that the HSE had approved a full-time psychiatrist to work there. Serious attempts have been made over the last number of years to fill the post but without success. Over the last number of years, we have been providing services to Castlerea on a wing and a prayer with some part-time psychiatric input. Professor Kennedy himself used to travel there from Dublin to provide half a day or a day a week to assess people. We are continuously trying to find somebody who will attend the prison on a regular basis to continue the management and treatment of prisoners. Very acute people are admitted to Castlerea from courts in the west and north west. They are met by a nurse and a GP but there is nobody to screen or assess them and there is no one to continue their ongoing treatment if they have been in treatment in the community. If we have someone who is very ill, we must transfer him in a prison van for either two hours to the midlands or three hours to Dublin which is away from his zone, family and connections. It is an absolutely acute problem. The prison governor, Mr. Martin Reilly, brings this to my door every week and raises the risks to prisoners and the pressure on staff. Prison officers are left to manage this untreated group of mentally unwell people in Castlerea. It is difficult to get services to places like Castlerea. We have recently provided psychology services, but my biggest risk today is Castlerea.

Can the nature of that risk be teased out further? Can it be explained in terms of the risk posed to other inmates and staff?

Mr. Michael Donnellan

The ultimate risk is mortality, which is to say the risk of death posed by untreated people to themselves and to their fellow prisoners. There are also risks to our staff who have to deal with acutely mentally unwell people and manage them to ensure they have their food, recreation and exercise and attend all necessary sessions. Some prisoners may be acutely unwell. The minute one opens their cell doors, the violence that emanates from the room is enormous. Prison officers are managing this on a daily basis.

How is that managed on a daily basis? I ask Mr. Donnellan to forgive me for asking all these questions but I am trying to understand. Is the prison using its resources to manage prisoners one-to-one when prison officers should be used to do other work? How are the resources being provided and managed?

Mr. Michael Donnellan

The IPRT is right to say that many of these acutely ill people end up behind the door of a cell for 20 or 21 hours a day. They can only be managed outside their cells for two or three hours due to the resource issue. This goes right across the Prison Service. For example, we have 15 very unwell people in Cloverhill today. Their regimes attract resources away from the ordinary prison population because sometimes very unwell prisoners must be managed through what we call "barrier handling". That means four or five prison officers are required to manage one person to move him safely from point A to point B.

It is shocking. I thank Mr. Donnellan.

Mr. Bergin and I know each other from the children's committee and I am delighted he is here today. One of my questions relates to the release of children from Oberstown. What programmes are involved and how does the ACTS team work with the community to integrate these children? I have been to Oberstown and I have seen the wonderful work Mr. Bergin and his staff are doing out there. However, I have a concern about vulnerable children who have come from addiction and violent backgrounds and how they are reintegrated to have a reasonable chance at life.

Mr. Pat Bergin

ACTS was a national service. A team of professionals was established by Tusla and based in Cork, Dublin and Limerick. They worked as a team to follow the young people through the care services, whether it was young people in the community, in special care high-support units or in detention. The idea was that they would be familiar with those young people and be able to pass on the intervention each clinician had to a relevant clinician in the relevant area. When young people were leaving us, the ACTS team could move with the child or young person. There has been a review of ACTS and, rather than having one national team that moves with the children, five teams have been established, including in Cork and Limerick. The five teams cover the north, south, east and west and there is one in Oberstown. The idea is that they will continue to work together. The team in Oberstown will work with young people. If a young person goes to Cork, the team in Cork will pick up the support services and work with the young person in the Cork area. What was happening was that staff were travelling all over the country and were not in a position to provide a robust service. They spent more time on the road than on delivering services.

Does that cut down on repeat offending and repeat presentations to Oberstown?

Mr. Pat Bergin

The focus is on ensuring that the time clinicians have is spent on the delivery of services to young people rather than on travelling. As to the repeat offending piece, part of what we have found more often than not when a young person comes to Oberstown is that the ACTS team is already familiar with that child. The information we can get quickly is very helpful and allows us to look at how we will manage particular behaviours and what services we need to put in place. From that perspective, it is excellent.

The challenge in moving young people back into communities is not only around the ACTS team but around all of the ongoing services. Part of what we identified last year when we looked at the young people coming into the service included existing identified needs, whether in education, mental health or substance misuse. The difficulty is ensuring that young people access those services in the community. What are the support mechanisms either through the family or through communities themselves? Part of what the ACTS teams and our team have been doing is looking at how we can effect change with parents. We have Le Chéile and YAP working with families so that when young people return home the families will know the clinician or psychologist is available and will call to the house and can support the young person to engage. It is about changing the model. There is a challenge but it is the connectivity.

How is single separation being managed in Oberstown at the moment? It is something that arose in one of the reports.

Mr. Pat Bergin

There is a significant focus on single separation, which is a complex matter as the Deputy knows. On a daily basis, we have a system in place which looks at what young people are in single separation. There were two young people in single separation this morning regarding incidents which occurred last night.

We are reducing the level of time of single separation. It is being monitored right through the organisation, from my office down the line. The focus is on having alternative options. Some of the examples highlighted in respect of complex prisoners being managed behind doors are similar in some instances. It is about having those alternative approaches. We are constantly looking at reducing the amount of single separation, looking at what happened and why it has happened and at the contributor factors. We are reducing single separation all the time, but it is a constant issue.

I thank Mr. Bergin.

I thank the witnesses for their submissions and for the work they do. We do not do that often enough. We need to constantly recognise the work of the groups that appear before this committee.

In preparation for this meeting, I went through different cases and looked at some of the headlines, including headlines such as "court releases man as Central Mental Hospital full", "unmedicated and untreated patients at Central Mental Hospital moved to jails because of bed shortage" and "mentally ill patients being kept in prison due to bed shortages". That gives a flavour of the difficulties in society.

Ms Malone said that services are at crisis levels. Professor Kennedy described the services as being at the edge of safe levels. Clearly, there is a crisis in services. We know the Portrane facility is being built and will be ready in 2020, but will that additional capacity resolve the bed crisis in the system?

We know the prison population reflects what is happening in society. There is a crisis in homelessness. Increasingly, we see that the young people involved in selling and taking drugs are getting younger and younger. I know of children as young as seven years of age acting as runners for drug dealers. That is possibly the profile of young children coming into the prison system. Many of the families contacting public representatives tell us their son or daughter has a mental health issue and that they believe their child will be safer in the prison system. Is that the experience of the witnesses?

We heard about overcrowding, violence and so on which are part of the system and the fact that some jails are probably more dangerous than others. We speak of the need for a 24-7 mental health service in the prison service. Are there times when 24-7 mental health services cannot be delivered? Are some prisons worse than others in that regard? Is it worse at the weekend with staff not available and so on?

Mental health screening was mentioned. St. Patrick's Institution was mentioned and the 23%, and I suppose that screening was done a number of years ago. We do not have the staff in Oberstown. Is that screening going on anywhere else? Will it be higher because of the problems on the outside?

Solitary confinement was mentioned in one of the submissions. Of the 514 prisoners on a restricted regime, 325 had been held on 21-hour lockup. The duration of the time is not generally published. Some 51 prisoners were held in solitary confinement in January 2016, of whom nine had spent more than one year in isolation. Is solitary confinement used as a means of controlling prisoners, many of whom may have mental health issues for which the supports are not available?

I invite Professor Kennedy to answer the first few questions.

Professor Harry Kennedy

I thank Deputy Crowe for his questions. Currently, we have two secure forensic beds per 100,000. Most other countries have between five and 14 beds per 100,000 of population. When we move to the new hospital in Portrane in 2020, we will have 3.5 secure forensic beds per 100,000, comparing like with like. It will give us breathing space, but very short breathing space. I suggest that we need to start planning what comes next which will be a greater tailoring of services, according to need. Within the secure hospitals, we will need admission beds, rehabilitation beds and some slow-stream beds, recognising long-term needs which are currently not planned for or recognised in the system we have.

The Deputy asked whether people are safer in prison. That is a really difficult question to answer. I think many people access mental health services for the first time when they come into custody. There are really complicated reasons for that as well as many different reasons, including stigma, but also because general adult services, and I cannot sufficiently emphasise this, are all part of the same service. While I am obviously explaining to members the problems in the forensic part of the mental health service, we are an integral part of the mental health service and it all hangs together. If there is a pressure in one part, it invariably passes up the stream until it lands in the criminal justice system and with us. We are in that sense the canary in the mine, the barometer. If we are having significant problems, it is because there are not only not enough resources for severe mental illness but not enough tailoring and diversity of the type of services. One needs admission beds and intensive care beds. We also need longer term beds and a variety of things within a forensic mental health service and a general adult service.

We have taken community and in-reach services in the prisons in our aftercare services about as far as we can. An endless response to these difficulties is to say that we need to do more in the community but that is not the answer to every question.

I thank Professor Kennedy. Was everything Deputy Crowe asked answered?

The reason families think their children are probably safer in jail is that they cannot get access to services in the community. They believe that by going into prison, they will at least have somebody to identify whatever mental health problems their child has. These families are desperate because their sons and daughters are involved in all sorts of criminal activity, but much of it is down to their mental state. Will somebody respond to my question on solitary confinement?

Mr. Michael Donnellan

That is a big issue but there are many reasons people want to serve their sentence behind the door. We like to call it a "restricted regime" rather than solitary confinement. On admission to prison, a number of prisoners will say they want to do their sentence behind the door because they feel at risk being out in the general population because of drug debts or money owed by members of their families outside. Obviously gangland stuff is playing a major issue in the running of our prisons. There is that threat in prisons from people of that persuasion. Of course, there are people with mental health problems. We have worked really hard on this in the past number of years to get our number on this restricted regime down, but the Deputy is correct, that on any one day we do a survey of who is behind the door, we will find that there can be eight to 12 people who are only getting two hours out-of-cell time during a 24-hour period. That is for all sorts of complex reasons, violence being the number one reason. Coupled with that is the whole threat that goes with it. It is about trying to manage this disparate group of people in prison and trying to ensure that everybody gets a minimum of two hours out of their cell per day. Of course, the vast majority have a normal regime. There are many complex reasons people are in solitary confinement or on a restricted regime.

When one assesses any case, one will find all of those reasons. There is a prisoner in Cloverhill Remand Prison who will be released in two weeks who will not come out of his cell until the day he is released. Every night I must sign an order that allows him to stay in his cell, rather than physically force him into a regime. He has threatened that he will do damage if he is forced to do so. There are all sorts of reasons people want to serve sentences behind a door, but we know how damaging it is. We know about the isolation and psychological damage caused by being in that kind of environment for a prolonged period.

Ms Deirdre Malone

In February 2018 the Irish Penal Reform Trust published research on the effects of being in solitary confinement and on restricted regimes. The director general is correct insofar as we have found that the vast majority who are participating in that regime are requesting it because they fear for their lives or safety. There is a very significant structural issue if there is that number of prisoners in the system who fear for their lives or are in fear of an injury. It is a significant concern. The reason I have raised it at this hearing on mental health is, as the director general said, we know that the impact of that type of regime on mental health is so severe and significant.

On families saying they feel their loved one would be safer in prison, I have had the same experience where a family member has told me something similar. We face a dire situation if families are so desperate about the lack of mental health supports and services that they would rather their family members go through the criminal justice system to access health services. That is not acceptable.

I thank the delegates for their presentation. The new forensic unit planned for 2020 will maintain a breathing space and that is about all. This week I believe there are 36 people in the approved centres and prisons on the waiting list for treatment, which seems like a small number. I imagine the average waiting time probably runs into years.

I refer to those in prisons who are not receiving treatment or refusing it in any form, whether it be medication, talk therapy or otherwise. They often complete their sentences and are discharged. That creates the revolving door through which they return with the same mental health issues.

Having involuntary status within prisons or approved centres can sound horrific. I am not referring to the Central Mental Hospital. How do the delegates view it? Perhaps the different individuals might answer for themselves.

Professor Kennedy referred to changing a unit or units in prisons into designated approved centres. How would that work in practice? Is it not anathema to all of the work being done on the stigma attached to mental health and the efforts being made not to enforce the receiving of treatment? To enforce the receiving of treatment during imprisonment seems like a double whammy. For years there have been rumours, but can the delegates give us an idea of the plan to have different wings in prisons designated as approved centres, whereby they would become psychiatric centres? The Criminal Law (Insanity) Act 2006, which was related to the Central Mental Hospital, provided for something similar. I expect something like it would have to be done if there was to be such designation in prisons. I have been hearing about this for years and have a great interest in it. I remain unconvinced or unsure of its wisdom, but I may need to reflect further on the matter.

On Cloverhill Remand Prison and the lack of a specialist forensic psychiatrist and the inability to recruit one, how many forensic psychiatrists are there in Ireland? Many healthcare services use locums who may last six months or, if one is lucky, a year to fill the gaps, although they are not trained in the specialism. This is a particular problem in child mental health services. Representatives from CAMHS have been before the committee and we know that this is happening in that sector. Has the Irish Prison Service used locums and, if so, how long have they lasted? Have they been trained in this specialism? I presume the answer to the last question is "No."

I always advocate for the use of advanced nurse practitioners. They need to be used in order that we can benefit from their skills, education and critical experience, especially when there are shortages in every area of the public health service.

I cannot agree with the delegates on A Vision for Change. It is incredible that they think we should just bin it. It was published in 2006. Some 73% of the recommendations made within it have never been implemented, but I am not going to go through another 12 years of attempts to come up with another document which would sit on a shelf and gather dust. There is an oversight group which we will have the pleasure of meeting next week at 5.30 p.m. The delegates should be proactive and actually write to it and take responsibility for changing the oversight group within the mental health service, the prison system and the Central Mental Hospital. It is not rushing to engage with the delegates, but neither has it rushed to engage with us, with the exception of prods here and there.

I refer to the skill mix within the Central Mental Hospital and other prisons. Nursing staff were brought into some of the other prisons about a decade ago. How is it working out? Is the culture between custodial and healthcare staff knitting together and supportive? There is much talk about the skill mix. In 2012 the Labour Court recommended a skill mix in the Central Mental Hospital, but capped the figure at 10%, although I think it may have increased in the past six years. There is increased use of restraints, medication, assessment and special sittings, one to one, two to one and, in some cases, five to one. They can only be carried out by registered nurses.

The Senator is asking a lot of questions.

How far can we push out the skill mix without losing quality and safety aspects in ensuring the risks are reduced?

I have many more questions, but I will just ask one more. The delegates are seeking to have an overall chief psychiatrist which is probably a good idea. I imagine Professor Kennedy could write the job description for the post. Recently, I dealt with a case in which an approved centre had refused to take an individual patient for reasons related to the safety of the rest of the patients in it. In the United Kingdom under legislation they must take such individuals. Do the delegates think we should take a similar route?

Last August I had research carried out into the matter of community treatment orders. Will the delegates say where they stand on the matter? I am not sure I see it as pluses and minuses, but we should consider implementation of something similar if it could save some families from being murdered, which happens rarely but not rarely enough.

I thank Senator Devine. She is way over her time and she posed quite a few questions. I am going straight to Mr. Donnellan because some of the Senator's questions were directed at him.

Mr. Michael Donnellan

I wish to correct Senator Devine. Cloverhill has excellent in-reach psychiatric and forensic services. Was the Senator referring to Castlerea?

I am sorry, it was Castlerea.

Mr. Michael Donnellan

We will take anyone in Castlerea - a senior registrar, a locum or anyone who would give us any respite. It is, however, nearly impossible to get that kind of resource into a place like Castlerea. We are always clutching at straws and it is very difficult. However, Cloverhill has excellent services. It is probably the most resourced prison in the country.

On skill mix, my colleague, Mr. Enda Kelly, is the manager of nursing. We have many nursing staff in our prisons. I ask him to comment.

Mr. Enda Kelly

Registered nurses comprise 90% of healthcare staff in prisons. There was a reference to how the culture between the officers and the nurses worked. It is hugely supportive. Over the decade I have been with the Prison Service, we have seen great development in joint training between nurses and prison officers. That is especially the case with mental health. Nearly 1,800 of our staff are now trained in mental health awareness. We see that nurses realise that they cannot function without the daily support of the prison officers. That brings me back to the question of people in isolation. I would like to clarify that it is never done as an easy way to manage somebody with a mental illness. We have a seclusion policy which is akin to a clinical seclusion policy but it is tightly regulated. It has to be prescribed by either a registered nurse or a doctor. The skill mix between the nurses and the prison officers is hugely successful. It has been the basis for many of our projects in the high-support unit where we have been able to enhance the quality of life for people in prison with major mental health problems.

That also touches on the involuntary status of prisoners. We cannot forcibly treat prisoners against their will. Anybody with a healthcare issue of that severity - be it a cardiac or mental health issue - deserves to be in a clinical setting. If a prisoner is that ill, we clearly advocate that he or she should be properly treated and supported by our colleagues in a hospital in the community. We are in the invidious position, as Professor Kennedy said, that we cannot get access. It is important today that we mention the human cost involved. These are people who are suffering and are terribly unwell and as an organisation we are trying to do the best we can to support them. We have professionals and all the experts in but we do not have the right environment.

That is fine.

Mr. Michael Donnellan

We were all asked to comment on the approved centres. It is something that has been out there. We are prepared to talk about anything. It is a big shift in the thinking for mental health that prisons would become psychiatric units where people can be forcibly treated. It is a discussion that is needed and one we have to have among all the stakeholders, including the Minister for Health, Deputy Harris, the Minister for Justice and Equality, Deputy Flanagan, our inspectorates, the Mental Health Commission and all the oversight groups. They would all have a view. It may be something we need to talk about.

Let us not implement it without talking about it.

Mr. Michael Donnellan

No, and Professor Kennedy made that point. In the meantime, though, all of these untreated people are in prison.

Does Professor Kennedy want to add something?

Professor Harry Kennedy

If I can. We have 11 consultant forensic psychiatrists and in the new hospital we plan to transition to having many more than that. Of those 11, 2.5 are providing prison in-reach full-time. All of us provide in-reach services to different prisons in varying proportions of part of our weeks. We need to increase that greatly as well. Today, there are 28 people on the waiting list in prison. Others are on other parts of the waiting list. The committee has been briefed on that.

That was a parliamentary question.

Professor Harry Kennedy

Yes. The question of skills mix is both an industrial relations, IR, and a professional issue. I think IR might be a conversation for elsewhere.

I thank Professor Kennedy.

I also had a question on Professor Kennedy's opinion on community treatment orders.

I ask Professor Kennedy to be brief.

Professor Harry Kennedy

The Criminal Law (Insanity) Act was revised in 2010 to give us a useful, practical and effective power to conditionally discharge. It has been a huge success when selected appropriately for people where it is a proportionate and clinically helpful thing to do. The crucial thing about extending it more broadly to different groups is having proper evidence that it is effective. Whether it is a good idea or a bad idea is not a way of telling whether it works - and whether it works is the only question of benefit to the patients. We need to do much more research in Ireland on what works here. That is not happening.

I thank Professor Kennedy. Before I call Deputy Browne, I have to ask a question or I am just going to die. Professor Kennedy spoke about recruitment and how there were no recruitment problems at all when it was being handled internally. Then it went to going through the HSE panel process. If the old process was so successful, why did it go to the HSE and when? I agree it should be an internal responsibility.

Professor Harry Kennedy

I stand to be corrected on the question of when but it was some years ago, perhaps five or six. I am not great on the exact detail of when that was. On the question of why, I was told it was national IR rules about recruitment and licensing for who is entitled to recruit. Prior to that, every clinical service within the HSE did its own recruitment and it worked better that way because people either chose to work in a specialist service like ours or they did not. We have had mixed results with panels. It has been better lately than it was before but it could be even better.

That is fine. We will bring this to the Minister's attention and especially what we have heard today. I call Deputy Browne.

My question is more for Professor Kennedy. In 1950, there were 7.9 beds per 1,000 of the population and 22,000 citizens were hospitalised in psychiatric hospitals. According to the Health Research Board, HRB, there were 17,290 admissions in our hospital psychiatric units in 2016. That is a rate of 376 admissions per 100,000. The HRB went on to state that the rate of involuntary admission in 2016 was 48.4 per 100,000. It is 120 in the UK. That is almost double the rate of involuntary admissions. In the EU 28, Ireland has the third lowest number of psychiatric beds per 100,000 according to EUROSTAT. That is a dramatic change over the last 60 years. The EU average seems to be 72 psychiatric beds per 100,000 and, according to EUROSTAT, in Ireland it 35 per 100,000. That is again less than half of the EU average.

Professor Brendan Kelly has been reported saying, "These are stark differences and strongly suggest that Ireland has insufficient psychiatric beds to serve our population." He went on to say that the "movement away from the excessive inpatient care [in the] 1950s ... towards the present situation [when the] rate of involuntary admission is less than half of that in England, and [that] Ireland’s availability of psychiatric beds is less than half of the EU average." He continued that "the key human rights issue in Irish psychiatry today is not [the] disproportionate denial of the right to liberty due to over-custodial care, but, rather, issues concerning the right to access to an appropriate level of care when it is needed, including inpatient care". That would seem to chime with what Professor Kennedy said earlier. Does he think that decongregation - that is the buzzword used - has gone too far? Has it become either an ideology, or worse, a badge of convenience to effectively shut many units that perhaps, it would have been better to have replaced or done up? I have heard this reflected elsewhere.

Have we gone too far such that the policy is no longer based on the clinical need of the individual but on getting as many people as possible out into the community, irrespective of clinical need and what community supports are in place for them?

Professor Harry Kennedy

It is interesting to compare my colleague Professor Brendan Kelly's assessment of the situation because he works in the very busy general adult service in Tallaght Hospital and he has previous experience of working in the north inner city as well. All parts of the service are having the same experience. All of the contributory experts - those of us who do this - are coming to the same view from different starting points. I would go a little further. I think the EUROSTAT figure for Ireland of 35 per 100,000 lumps in community hostels, old age intellectual disability and other things. The HSE number is 20 per 100,000. Comparing like with like with the EUROSTAT number, the situation is even worse.

The system, following A Vision for Change, was driven by ideology independent of expertise and independent of the research evidence at that time. A lot of new evidence has emerged since. For instance, the UK rate of admission under the Mental Health Act has increased in recent years. It was previously lower than the 120 per 100,000 that it is now. Forces of nature in the population cannot be blocked by ideology. There is a certain amount of severe mental illness in the community. People have genuine needs for levels of care and treatment, which bring us back to this position. The old asylums were impoverished and negative in every way for all kinds of very interesting reasons. There was a choice between reforming them or closing them and the choice was to close them. The obligation on us now is to find something better. The way to do this is through reawakening the concept of excellence in clinical services. Excellence is how we keep up with what is happening in the population that we serve. It will never be the same each decade and so the only way to keep up and ensure we are genuinely meeting the needs of people with severe mental illness and all the range of mental health problems is through the virtuous circle of research, leading to the development of better services; teaching so that we are constantly preparing new professionals in these newly-developed services and training for postgraduate work to provide the people who will do the next round of research, development and teaching. Other countries have centres of excellence funded continuously to keep up in this area. The Italians have an excellent centre of excellence in Brescia in northern Italy. The Dutch have an excellent centre for forensic expertise in Utrecht. Most other countries have these centres; we have nothing of the sort.

There is evidence of increasing patient violence against staff, the reason for which according to the staff with whom I have raised this issue is that the type of drugs being misused and abused by patients has changed. For example, 20 years ago they might have been misusing and abusing hashish, marijuana, heroin and benzodiazepines but they are now misusing poly drugs, which means they have moved from drugs which had a docile effect on them to drugs that have an energetic effect on them. Perhaps the witnesses would comment on that issue and also on the level of research here into mental health versus other countries.

Mr. Enda Kelly

The Deputy has raised a very interesting question. We have spent a lot of time with our international colleagues looking on the drugs in prison issue. The Deputy is correct that there has been a big shift from the drugs of choice in previous years, namely, hashish, marijuana, heroin and so on. Nowadays, people do not know what they are taking. They may be told that what they are being given is ecstasy, a benzodiazepine or a roche but that may not be the case. When people take these drugs the onset of acute psychosis is so rapid it causes a massive management problem for the person in the prison environment or the clinical environment outside of the prison.

In terms of how we as clinicians respond to this, all the international evidence is to treat symptomatically. For example, one should try to keep them cool because they overheat and their temperatures spike and to try to keep them in a safe environment. We are finding that once the psychosis passes, these people have amnesia. They often are missing up to a week of their lives where they cannot remember what happened.

Responding to the drugs people are taking is a huge challenge. We work closely with the State Laboratory in terms of trying to analyse what we find when people take these drugs. The State Laboratory and all laboratories across Europe are having trouble keeping up with the chemical formulations that are being put out there. We are very much working in the dark, which underlines the need for the dual diagnosis service. We need to get comorbidity tackled. There are a lot of people with mental health problems not only in prisons but across the whole country. There are not silos of mental health on one side and drug addiction on the other, these are married inextricably. The Irish Prison Service has committed in the national drugs strategy to work with the HSE to take a lead on developing dual diagnosis because we are a service that can initiate that help and treatment as soon as a person presents to us.

I have a few questions for the witnesses. My first question is to Ms Malone. In regard to the inadequacies of the mental health service, has this been brought to the attention of the HSE or the Department of Justice and Equality? My next question is to Mr. Donnellan. He mentioned that 30% of the population in Castlerea Prison are from the Traveller community. Is that reflected anywhere else in Ireland? We are quite concerned about Traveller mental health.

My question for Professor Kennedy is, was he included in the planning of the Portrane facility and why did we not know that more beds were needed? Mr. Hernon might tell us how many children with really severe enduring illnesses there are in the Oberstown facility.

Ms Deirdre Malone

I am open to correction but my understanding is that the Department of Health does not have responsibility for the provision of mental health services within the prison system, but that this service is provided by the Irish Prison Service.

I note Professor Kennedy is nodding. Is that not the case?

Professor Harry Kennedy

It is a complex mix. The national forensic mental health service, which provides multidisciplinary teams, is a HSE service. The drugs in-reach service is a HSE service. The psychology service is provided by the Irish Prison Service. Primary care, general practitioners and general nurses are provided by the IPS and we work in a multi-agency way. For example, probation is a criminal justice service but with social work background and increasingly we are providing mental health social workers as well as part of a pre-release plan. It is a really complex interagency service at which we are fairly good.

Mr. Michael Donnellan

On Travellers, following a report by the IPRT a number of years ago, we have worked with the St. Stephen's Green Trust about a Travellers in prisons initiative. We have been working with the national Traveller organisations and one of their key points was that if Travellers are not counted in prison, they will not matter. We have agreed to take a real census of every person who comes into prison and ask them for their ethnic origin. We did a pilot at the Dóchas centre at Castlerea and 30% of prisoners on a given day last month identified themselves as white Travellers. We intend to continue that survey and by October have all prisons done. We will have a scientific fact for how many Travellers occupy prisons, and it seems to be disproportionate. Travellers make up 0.6% of the Irish group and if they make up 30% of the Castlerea prison population, we can see that is disproportionate to other groups of Irish citizens in prisons.

I am sure we would love to ask millions of questions about Travellers but we do not have time now. I asked about the planning at Portrane.

Professor Harry Kennedy

My colleagues in the senior management team for the National Forensic Mental Health Service have spent, more or less, half our working week for the past four or five years directly involved in planning. Why are the numbers not stacking up? A story against ourselves, in a sense, is that going back more than ten years ago, we surveyed the population in need of hospital treatment in the Irish Prison Service and the criminal justice system. We did gold standard epidemiological surveys of need and we published extensively in research literature. A full report was lodged in the Oireachtas Library. It indicated a need for approximately 350 beds. The planners in the Department at one stage saw the 350 figure as an argument for 170 beds. I said to Senator Devine earlier that industrial relations are not the same as professional issues. People do not get the difference between research and expert evidence and bargaining. It is not bargaining; it is objective evidence.

It is fact.

Professor Harry Kennedy

We are where we are.

Mr. Damien Hernon

Mr. Donnellan spoke about Travellers. In the first quarter of 2017, approximately 23% of the population in the detention school were Travellers. In the first quarter of 2018, that figure is approximately 25%, so it is a consistent number. The ratio of Travellers to non-ethnic groups is very high. Approximately 30% to 50% of kids presenting on campus have mental health issues to varying degrees.

How many have severe enduring illnesses?

Mr. Damien Hernon

The numbers are pretty low on the severe end. There may have been two or three cases in the past couple of years. The cases go from mild to severe.

Professor Harry Kennedy

There are approximately four young people in Oberstown today who are on anti-psychotic medication. We are diverting perhaps one per month to inpatient services in the HSE, and we are having some success in doing that. It would be better if we had the secure forensic beds open and they will be open in two years.

We have discovered some consequences where there is a lack of beds. For example, in Deputy Browne's constituency, there are no child beds in the CAMHS unit Wexford, and there are also none in Waterford. It was suggested that there could be a day programme. Could that work with some of the prisoners who are mentally unwell? Would it be more economical and make more sense to do that, especially in light of the waiting lists?

Professor Harry Kennedy

It is a complicated question. The young people in Oberstown have 24-7 care to a very high standard from trained social care workers.

I apologise but I meant for adults. Could we do the same type of thing - a day programme - for adults with mental health issues who are on waiting lists?

Professor Harry Kennedy

Would that be in prisons?

Professor Harry Kennedy

We are doing that. For example, there are two high support units, one in Cloverhill and one in Mountjoy. There are others developing in other places. We have taken that as far as we can. We have 323 on our caseload in the prisons, which is almost 10% of the prison population. Of that 323, however, 28 are too ill to be in prison and should be in the CMH. They are on the waiting list.

Mr. Michael Donnellan

People who are very ill also have serious charges pending, often associated with violence. There is no way they could be accommodated in a day programme in the community.

Ms Michelle Martyn

With regard to designated centres, there was a recommendation in the Report of the Commission of Investigation into the Death of Gary Douch a long time ago. There is a prolonged waiting list of 28 to 30 per day. Whatever way it goes. whether it is a designated centre within the prison or outside the prison, as the CPT recommended, mentally ill prisoners should be kept and cared for in a hospital facility that is adequately equipped and which possesses appropriately trained staff. In the view of the CPT, the facility could be a civil mental hospital or a specifically equipped psychiatric facility in the prison system. Whatever course is chosen, the accommodation capacity of the psychiatric facility should be adequate and there should not be a prolonged waiting period before a person is transferred to a psychiatric facility. It was noted in the Gary Douch report that this should be 72 hours and, in the UK, there is a recommendation of 14 days. The transfer is quite low at 34% but we do not know how many prisoners are waiting to be transferred here, the length of time or the number of prisoners in special observation cells. Mental Health Reform indicated last year indicated an individual was in the system for 8.5 months. Now is the time to decide.

Who is responsible for the research on prisoners who are on the waiting list? Ms Malone made the same comment at the beginning of the meeting. There is no research on how long these prisoners are waiting, who they are and what is happening to them.

Ms Michelle Martyn

We need the data first. A member made the point about research, which is generally quite underdeveloped in Ireland, including in the Department. In other jurisdictions, it is much more developed but it is quite limited here, as is the data.

Professor Harry Kennedy

We have the best researched population probably anywhere at the moment and we constantly publish evaluations of all our services. All the data are available.

Does that include prisoners on waiting lists?

Professor Harry Kennedy

The problem is turning that into developed services and then going further and researching to develop better treatments.

We are talking about research on prisoners on waiting lists rather than evaluating what is there. Is there anything in that regard?

Professor Harry Kennedy

We have all that data and we are fully informed about that. Getting back to the point about how to use services in prison even better than they are used at the moment, given that there are clear deficiencies, everybody who needs to be treated in hospital should be treated in hospital. The difficulty is having somewhere safe to send people back to who have been treated. Invariably, they will relapse on being returned to a prison. It would be helpful to have, as the CPT notes, designated centres in prisons that would be drug-free and where medication could be continued after the acute phases of treatment. It would be a practical solution to a practical problem and would take matters forward a bit.

We will include all the statements in our report. Could we have the information on prisoners on waiting lists? We would like to include it in the report as well.

Professor Harry Kennedy

If the Chairman can list what she would like, I would be happy to do that.

We will send a letter during the week if that is okay. I thank all the witnesses. This has been an extraordinary meeting. They have told us things we have never heard and which are difficult to listen to. We will let them know about our report when it comes out. We are trying to keep a promise that it will not gather dust on a shelf.

The joint committee adjourned at 3.40 p.m. until 5.30 p.m. on Wednesday, 30 May 2018.