Mental Health Services' Funding and Performance Indicators: Discussion

From Mental Health Reform, I welcome Ms Shari McDaid, director, and Ms Kate Mitchell, senior policy and research officer. On behalf of the committee, I thank them for their attendance. The witnesses will be invited to make a brief opening statement, followed by a questions and answers session. I hope they will forgive the low attendance. Many members are currently voting in the Houses as there is pressure to pass legislation before the upcoming summer recess. I remind the witnesses that the proceedings are recorded and held in public. Their comments will be noted in our report.

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

Members should be aware that, under the salient rulings of the Chair, they should not comment on, criticise or make charges against a person outside the Houses or an official 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 put them on flight mode because they have an impact on our sound system.

Any submissions or opening statements the witnesses make to the committee will be published on the committee website after this meeting. I invite Ms McDaid to make her opening statement.

Dr. Shari McDaid

I thank the Chair and members of the committee for inviting Mental Health Reform to appear to discuss the important topics of funding and performance indicators for the public mental health system. We very much appreciate the opportunity to inform the thinking of the committee in preparing its upcoming report. We strongly welcomed the establishment of the Oireachtas Joint Committee on the Future of Mental Health Care, which signalled the priority of mental health as an issue across all political parties and provided an opportunity for Ireland’s mental health system to be scrutinised at parliamentary level in a new way. We also support many of the recommendations of the committee’s interim reports, in particular those on increasing the proportion of the health budget allocated to mental health, including development funding, the prioritisation of the development of a mental health information technology, IT, system and the expansion of the existing suite of key performance indicators in the mental health services, all of which are relevant to today's discussion.

Mental Health Reform is Ireland’s leading national coalition on mental health, with more than 60 member organisations which campaign together to drive progressive reform of mental health services and supports in Ireland. Since 2012, it has actively campaigned for increased funding for mental health services and supports for specialist mental health services and the mental health system as a whole. In addition, in pre-budget submissions for the past six years it has called on the Government to invest in and ensure the implementation of a national mental health information system.

Investment in mental health services must be understood as a question of resources for staffing because it accounts for 80% of expenditure on mental healthcare. Investment in public mental health services is about ensuring that the right people are in place and available to provide support to people in mental and emotional distress across the country. Between 2012 and 2018, €210 million in development funding was allocated to the development of new mental health services. However, it must be acknowledged that the investment occurred in the context of increasing demand for mental health supports and much of it was spent on areas of service delivery not specified in A Vision for Change. That does not mean that those are not very important and worthy areas. The amount invested in our mental health services is calculated based on the cost of implementing A Vision for Change but much of the development funding has gone to supports not specified in that framework, such as the National Office for Suicide Prevention and counselling in primary care. The funding has also been used to maintain existing levels of service in the face of increased demand, to obtain out-of-area placements for services for which we do not have the appropriate facilities in Ireland and to cover the cost of agency staff who cover unfilled posts. While the investment is welcome, it has been vastly outstripped by the challenges in the operation of the mental health services. The ongoing shortfall of investment in mental healthcare in the context of significant increased demand since A Vision for Change was published in 2006 has led to a system that is at breaking point and in dire need of financial attention.

In 2017, the HSE reported it required an additional €98 million to achieve the staffing for mental health services set out in A Vision for Change. This figure did not include investment in primary care and the voluntary sector for providing complementary supports. Accordingly, notwithstanding investment by successive Governments since publication of A Vision for Change, the reality is that upwards of 10% more funding is needed in today's terms and in light of today's demographics simply to fulfil the mental health services programme published in 2006. Millions of more euro is also needed to develop adequate capacity in primary care.

These figures reveal that a step change in investment in mental healthcare is needed. We must be much more ambitious than heretofore. We must think in terms of ensuring that everyone has speedy access to the mental health support they need. If not, the costs will be felt everywhere else in our health and social system, from higher costs for physical healthcare to higher disability and illness benefit payments to higher supported housing costs and lost productivity for employers.

A report published by the London School of Economics, LSE, identified total expenditure on healthcare for mental illness - the term used in the UK - amounts to some £14 billion a year. In addition, untreated mental illness amounts to more than £10 billion in physical healthcare costs each year. If the same model were used for Ireland, which has higher cases of untreated mental illness, that cost would be in order of €700 million.

The Healthy Ireland framework reports the economic cost of mental health problems in Ireland is €11 billion per year, much of which is related to loss of productivity. Similarly, a recent report published by the Work Research Centre, WRC, identified:

The economic costs of mental health disorders are enormous, with figures suggesting this may amount to as much as 4% or more of GDP in some countries. Although substantial costs accrue to mental healthcare systems, the main economic costs are located in the labour market and social protection systems, not just for those experiencing poor mental health but also for other family members.

The high burden of disease attributed to mental health difficulties highlights the need for adequate investment in mental health. The evidence based review on the refresh of A Vision for Change clearly identified:

Studies have shown the substantial returns on investment that a broad range of prevention and treatment mental healthcare interventions can yield. This may include better outcomes for the mental healthcare sector and for the physical healthcare sector, cost-savings arising from prevention, and substantial cost-savings and other contributions across other areas of the public sector, economy and society.

In addition, the World Health Organization, WHO, recently reported that every $1 invested in scaling up treatment for depression and anxiety leads to a return of $4 in better health and ability to work. That is a 4:1 return on investment.

In 2018, the total budget for mental health in Ireland is just €912 million. If fully realised, this level of expenditure will equate to just 6% of the overall health budget. This proportion represents a decrease on previous years and is severely lagging behind both national and international standards. Notwithstanding difficulties in comparing expenditure between countries, the WRC evidence review acknowledged that Irish expenditure was lower than better performing mental health systems. An increase in mental health expenditure is required not only for new developments but to maintain existing level of service costs. These costs increase each year due to demographic changes and other related factors.

Even though it is proving difficult to recruit and retain various specialist mental health staff, we believe it is possible to increase investment by broadening the scope of roles within mental health services and reserving scarce clinicians for roles they can uniquely perform. Mental Health Reform has consistently recommended a shift of focus in recruitment of staff from primarily medical professionals to health and social care professionals, including psychologists, occupational therapists and social workers. Currently in child and adolescent mental health services, CAMHS, there are fewer than 40% of the required number of clinical psychologists in post, fewer than 50% of social workers and fewer than 60% of occupational therapists. How can a holistic service be provided in that context?

While there is a fundamental requirement to invest in specialist mental health services, there is also substantial scope to develop mental health services elsewhere in the system, including in primary care and across the community and voluntary sectors. It is imperative that mental health is afforded financial parity of esteem in the wider health budget to reflect its significance in contributing to the burden of disease.

Mental Health Reform recommends increasing public expenditure on mental health services to 10% of the health budget within ten years and mental health staffing to ensure timely access to all relevant supports for anyone in mental health need, as well as population-wide prevention programmes. This investment must include resourcing services at all levels of the system, from prevention to community supports to primary care and through to specialist mental health services.

There is no national mental health information system to report on the full extent of service resources, provision, quality and outcomes for community-based mental health service delivery. Mental Health Reform has been calling for such a system in budget submissions since 2013. It is not acceptable that more than 12 years after publication of A Vision for Change, there is no information system to account for the performance of more than €800 million in public expenditure on mental health care each year. There is widespread acknowledgment of the importance of such a system from national and international experts, the Mental Health Commission and from the HSE. The development of an appropriate, electronic mental health information system based on key performance indicators, will assist in the full transparency and accountability for the evaluation, planning, funding and effective and efficient delivery of mental health services. The WHO's guidance and the UN's human rights framework can inform the creation of an appropriate framework for performance indicators. Such indicators are in use in England, Scotland, Canada, New Zealand and Australia. Mental Health Reform recommends introducing a national, electronic mental health information system within three years of completion of the review of A Vision for Change to enable the planning, implementation and evaluation of service activity. It also recommends developing up-to-date key performance indicators that show delivery of human rights standards and national mental health policy within one year of the review.

We are concerned that the restructuring of governance and accountability mechanisms within the HSE this year has led to the dissolution of the HSE's mental health division and national director of mental health position. It is vital that coherent leadership in mental health at the national level is not lost in the new HSE structure and that there is clear authority and accountability for a distinct, national mental health budget each year and driving reform of the mental health services.

Committee members may want to consider making proposals in this regard in the context of legislation which we understand is due before the Oireachtas to increase the HSE’s accountability more widely.

We welcome the wide range of recommendations made by the committee thus far in its interim reports. We ask members when issuing their final report to consider the following issues which we believe are in line with the committee’s terms of reference. We need to develop mental health services for particular groups that might not get adequate access, including older people, children and young people in the care system, people experiencing homelessness, people from the deaf community, people with intellectual disability, those with autism and people from minority ethnic communities.

We believe in establishing a national independent advocacy service for adults and children engaged in mental health services. We have heard so many stories of individuals frustrated at not being able to get the support they need and yet it is remarkable that there is no national independent advocacy service to support individuals to seek redress, to seek the services they need and to ensure their voices are heard by the services.

We need to ensure that the needs of carers and supporters of individuals with a mental health difficulty are attended to. We need to ensure the development of adequate services for people engaged in the criminal justice system. We must acknowledge that the criminal justice system is now sadly an ongoing part of the delivery system for our mental health services and that we must address the mental health need arising in the criminal justice system. We need to invest in infant and early years mental health services. We need to recognise and support the valuable, essential and complementary role of the community and voluntary sector in supporting people's mental health needs, including the development of peer-led services

The committee previously received our full submission containing a review of A Vision for Change. Further details of all those areas of concern are contained in that submission.

Given the scale of money involved in mental health and considering the lack of systems in place to track and support performance against such spending at care group level, our specific appeal to the committee today is that accountability in mental health funding and expenditure is prioritised in its final report.

I thank Dr. McDaid, who does sterling work and who has the resilience of thousands of people. I also compliment Ms Kate Mitchell. I do not know how they both have a full head of hair. I have a million questions but I will respect the members and call on them to ask their questions first. Members will be given seven minutes for questions to be asked and answered.

I thank Dr. McDaid and Ms Mitchell for coming in. I could not but agree with most of what she said. Based on working with Dr. McDaid for the past number of years, I know it is about setting out where she sees the improvements are required. She is preaching to the converted here on mental health, where it has come from and our vision for where we want it to be.

I have read the Mental Health Reform submission and have a good idea of it. It mentioned €98 million, a figure which came from the HSE. Did the HSE give any breakdown of that €98 million?

Dr. McDaid has kept a close eye on the overall findings of the committee and can see it from a different view with her experience. Given what the committee has examined, what are the top three quick wins that we can implement straightaway or relatively quickly given budget constraints and legislative constraints?

She said Mental Health Reform called for a general IT system in 2013. What feedback has been received from the Department or the HSE on that? Has it been costed? Has a feasibility study been carried out?

Dr. Shari McDaid

My understanding is that the €98 million is based on the number of vacant posts at the end of last year compared with the posts that were recommended in A Vision for Change. The HSE indicated it needed approximately 1,100 staff to meet the recommended numbers in A Vision for Change.

I think that was new posts as well as backfills.

Dr. Shari McDaid

It was posts additional to the ones in place at the time. It shows that some of the investment that has gone into measures that were not originally specified in A Vision for Change. That does not mean they are not positive valuable parts of the mental health system. For example, we support the National Office for Suicide Prevention, but A Vision for Change did not necessarily specify how much should be invested in suicide prevention. Similarly the development of services such as Jigsaw were not specified in A Vision for Change, but we all recognise they are playing an important role that has been worth the investment. The costing in 2012 for how much was needed each year to fulfil A Vision for Change has now changed because we still have many vacant posts that we need to fill.

While I know €98 million is a big number, we need to consider that it does not include investment in primary care mental health services or community and voluntary sector support. It does not include, for instance, investment in counselling in primary care or psychologists as part of primary care centres.

Is Dr. McDaid saying it does not include that?

Dr. Shari McDaid

It does not. The €98 million does not include that. We are currently spending between €6 million and €7 million a year on the counselling in primary care service. That is helping 11,000 people a year to get free counselling. The WRC estimated that 600,000 people, who might have a common mental health condition such as anxiety or depression, could benefit from such a service. The gap is enormous. Hundreds of millions of euro could be added to that €98 million. Every €1 added in increasing easy access to counselling and psychotherapy would give a €4 return on the investment because of lower healthcare costs for the rest of the health system, lower social welfare payments and increased productivity with people getting back to work more quickly.

What impact have the 114 assistant psychologists who have been hired had?

Dr. Shari McDaid

Ms Mitchell has just confirmed that they have been recruited this year but not fully come on stream yet they have not. It is hoped that they would have an impact with early assessment and intervention for people with some common mental health disorders.

I believe they will be targeted at children and adolescents. The cost would be about €3.5 million but this is only a starting point and we believe that access to counselling and psychological supports in primary care need to be ramped up. This will give rise to a reduction in pressure elsewhere in the health system.

Does Dr. McDaid believe the regulations brought in for counselling and psychotherapists will enhance the private sector industry, resulting in more people in the private sector going into the profession? That may lower costs for private sector treatment.

Dr. Shari McDaid

I am speculating but I do not think the regulation is to bring people into the profession although it will give those who are accessing private counselling or psychotherapy more confidence in terms of quality.

The fact that it is regulated sends a PR message to those coming through the school system and looking to go onto further studies. It suggests that it is regulated and is a medical-type profession.

Dr. Shari McDaid

I am not sure I am best placed to answer the question of the impact it might have in that regard. It is, however, a very welcome development and it helps to facilitate people availing of good-quality counselling psychotherapy but I do not think we have to wait for the regulation in order to increase access. The counselling and primary care service already has quality systems around using outsourced counsellors and psychotherapists and a HSE system is already in place to enable that. We really need to significantly increase funding for the counselling and primary care service. We need a substantial investment in all the options available to increase access.

What would be the top three wins of doing this?

Very quickly, please.

Dr. Shari McDaid

No. 1 would be expanding investment. A quick win would also be to extend child and adolescent mental health services to seven days per week from five, which would reduce a lot of pressure on families who are going through a very difficult time and need support. If the Deputy gives me another ten minutes, I may come up with a third.

I did not want to put Dr. McDaid on the spot but it is good to get a different perspective. We are in a bubble so it helps to see things from the outside.

It is a very important question. If we cannot get a top three of recommendations from Mental Health Reform, we are only blowing in the wind. I agree with Deputy Neville.

Perhaps the witnesses will have a eureka moment in two days' time. It would be more than welcome.

Dr. Shari McDaid

The Deputy also asked about feedback from the HSE. If there is more time later, I may be able to come back to that.

Dr. McDaid may answer it now, if she wishes.

Dr. Shari McDaid

Our understanding is that the HSE has had a couple of attempts at developing an IT system, with a proof of concept phase and a business case phase. It was asked to develop an interim solution and then it was told such a development would be part of the electronic health record. I would be concerned about that being a medium-term to long-term development. We feel there needs to be a greater sense of urgency in putting in place some basic information about what is happening in the mental health services. For example, we met with Mr. Stephen Mulvaney, the first national director for mental health, and simply asked him to ensure we knew what the waiting lists for psychological therapies were across the mental health services. It is a very significant indicator of the scope of provision and people who use mental health services have told us over and over again they want access to it as part of a holistic support structure, but we do not have it yet. We need to come up with a set of discrete indicators as a priority.

It is a perfect example of kicking the can down the road. There is a business plan-----

No costings have been done on an IT system.

I think costings were done. Was it something like €30 million?

Is there a budget for them?

Dr. Shari McDaid

I do not have that information and I am not sure there was a costing. What they are looking for seems to have changed.

That is in the nature of business as time evolves. As Dr. McDaid said, however, there is urgency in this and we need to get on with it now.

Senator Devine has gone to vote so I will continue. My bugbear is when people say they need an increase in budget but we do not know how they are going to spend what they are to be given. We have the highest budget per capita in Europe for mental health, at €900 million, but we do not know how the HSE is spending massive amounts of it. They use the excuse Stephen Mulvaney used when asked about the IT system, which is that they do not have the system which can show what is being spent. I am always questioning how we can know that we need an increase.

Ms Mitchell seems au fait with how money is being spent, such as when she said €3.5 million was for psychological services. That seems an awful lot of money for 114 psychologists and I would love to know how it is broken down. In the year since the budget I have been unable to get my head around the €35 million. Can somebody please explain, in very simple terms, what that figure means and at what stage we are with it?

It was said that we could save money by saving people, to the tune of €4 for every €1 invested. Why will the Government not do this? Why does it refuse to see the long-term saving from doing this properly? What is stopping it? I ask Dr. McDaid for real answers. We need the truth about what is preventing this Government and the HSE from improving our services.

Dr. Shari McDaid

I started to answer the question on how we know we need an increase. Even if we do not necessarily have enough detail about particular community mental health team support, and how much it costs, we do know the kind of supports people want when they are in severe distress. We know they want holistic support and want the option of psychological therapy, occupational therapies or social work support, such as with housing and other things. We know that there are not enough people in those roles to provide those things for everyone who is currently being seen in the specialist mental health services.

Often we hear anecdotally - we do not have the statistics because we do not have the information system - that a person's team referred him or her to a psychologist but the team said it would take six months or a year, and he or she has been waiting for that length of time. We would hear people talk about gaps in their occupational therapy support because their occupational therapist, OT, may depart or may go on maternity leave. The view was take at a certain point that we only need one of each of these professionals, for instance, there is one OT per team and one psychologist per team. That is not what A Vision for Change says but there was a strategic view taken early on in the implementation of A Vision for Change that it was better to have one in each team than to have a bunch in one team and not in another. That is a fair enough growth strategy but we never got to the multiples of these other disciplines that were supposed to be in the mental health teams. That means, simply speaking, that the 30,000 individuals each year who are referred in to the specialist mental health services are not getting the holistic support they should get. We would benefit from an in-depth evaluation of what happens in community mental health teams when someone is referred to them, what kinds of supports the person is offered, how well do those work, does the person recover and where does he or she end up in life. We do not have such evaluation and it would be useful to get that done. That does not necessarily mean that we should not ensure that those professionals are in place. That is just the mental health services, and then what I have been talking about is in primary care.

The WRC report is telling us that we are so low in our investment in giving people access to counselling and psychotherapy that there is a vast unmet need. We can confidently say that if we made that investment in greater access to counselling and psychotherapy for people with common conditions such as anxiety and depression, it would reap rewards. It would be a good investment and good value for money. That is the basis upon which I would say it is worthwhile making the investments.

Similarly, as we have argued on out-of-hours access to services, we have good evidence that where one provides out-of-hours access the referrals to accident and emergency departments drop. It is expensive to have people going into accident and emergency, and then some of them will be referred into hospital. We have good evidence that if one has good out-of-hours access to community-based mental health supports, one will have fewer people both referred to accident and emergency and in need of hospitalisation and it is value for money to make those kinds of investments. Those are the kinds of recommendations that we have made through the years. It is not pie-in-the-sky stuff. It is stuff that we know works.

The €35 million-----

Ms Kate Mitchell

Do you want me to take that question?

Dr. Shari McDaid

Would you like to take that?

Ms Kate Mitchell

Sure.

Briefly, before Ms Mitchell answers the question on the €35 million, I asked about the €3.5 million for the 114 assistant psychologists. That seems a great deal of money.

Ms Kate Mitchell

That €3.5 million is based on salaries only for the 114 assistant psychologists of approximately €30,000 for one year.

Ms Kate Mitchell

It sounds like a lot of money until one thinks of it in the context of all of the funding that goes into the mental health system.

It is for one year.

Ms Kate Mitchell

That is for one year.

Some €3.5 million for salaries of €30,000. Is my mathematics gone completely out the window because that does not add up?

Ms Kate Mitchell

It is €30,000-----

It is €30,000 by 114.

Ms Kate Mitchell

-----by 114.

I should not think so.

Ms Kate Mitchell

It is correct.

I am sorry, I am not questioning Ms Mitchell.

Ms Kate Mitchell

No, that is fine.

I merely wanted to know. Does it work out? It is €3.4 million. Ms Mitchell is absolutely right. From the beginning, I knew she was right.

Ms Kate Mitchell

That is no problem. That is how that breaks down. It sounds like a lot of money but when one thinks of it in the context of how much funding is going into the mental health system, it is very little.

I would echo Dr. McDaid's point that we need to invest in services and supports such as this to ensure that people get the supports they need when they need them, and that if we do that early intervention piece, it will provide a return on that investment.

Ms Mitchell is correct. It opens my eyes for the first time to think we are talking only about 114 staff members here at a basic salary and it costs €3.5 million.

Ms Kate Mitchell

I would add that while the appointment of the assistant psychologist posts is positive, there is a requirement to scale that up so that we see that type of investment both for all the child services and adult services across the country at the primary care level and to ensure that we get fully qualified psychologists as well and we are not merely bringing in staff at assistant psychologist level. We should have fully qualified senior level psychologists operating in that space too.

Okay, what of the dreaded €35 million?

Ms Kate Mitchell

As for how that is broken down-----

Does anybody else get it - the €35 million?

I will get my turn.

Ms Kate Mitchell

-----the €35 million is development funding and is allocated for new services. Often what we have found over the years is that such funding can be subsumed by existing levels of services. This is unfortunately because we know that there is such dire need for investment in new mental health services. Over the years, we have seen some of that funding going into services such as counselling and primary care, Jigsaw services and the National Office for Suicide Prevention. In budget 2019, that funding has to be boosted up. That is what we would be seeking. The €35 million is not enough if we are to adequately invest in the mental health services. If we are to see a change in terms of development of new services, we need to be considering at least €55 million for development of new services in 2019.

They should not deviate in any of the other areas.

Ms Kate Mitchell

That should not deviate to maintain the existing levels of services or agency staff costs. That needs to be focused specifically on new services.

I thank Ms Mitchell for that. I will go directly to Deputy Brassil here because I jumped the queue.

I thank the Chairman. I am trying to jump between two committees and it is not easy.

I have a few questions. As a committee, we are trying to come up with suggested solutions to the various issues that are coming at us. One of the principal issues that nearly every group that has come in to us pointed out is staffing, the lack of staffing and the inability to get staff in the key positions, particularly in child and adolescent mental health services, CAMHS, teams and adult mental health services. Consultant psychiatrists cannot be recruited. Often the consultant psychiatrist is the key person in the chain and as a result, referrals are not being made and key decisions are not being made because the person with the most important input is not there to make them. It is not acceptable any more to say that we are advertising the position, the position is funded but we cannot get the person. That is merely sending us around in a circle. Has Mental Health Reform any thoughts on what we could do or suggest as a committee about rearranging CAMHS teams so that we can fill them with staff? It might not be the ideal make-up but at least it is a make-up that can make decisions that can allow people to move on and get appropriate treatment and deal with 12 to 18 month waiting lists for young people trying to get into a service that they need today, not in 18 months time. That is what I would principally be interested to hear the witnesses' thoughts on.

Dr. Shari McDaid

We have a mental health service which is psychiatry led. It is orientated in such a way that essentially all the decisions have to go through the psychiatrist. From managerial decisions in terms of planning the service and the way the service is run to all decisions on individual cases, everything must start and end with the psychiatrist. Patients are admitted and discharged by a psychiatrist. While that expertise is invaluable, there is scope for more flexibility in the service than what we are operating currently.

We do not have clinical expertise so we cannot speak on whether one clinical perspective is better than another but we can say we are aware of some other countries that do not organise the service in that way and their mental health services are functioning and they seem to offer more ways for clinicians from different backgrounds to be the first point of contact or to make decisions around an individual case at different stages and at different points of the pathway.

It seems to me in the current context that we must explore how it is possible to loosen up the roles, not in a way that diminishes the quality of the support that an individual, a child or an adult gets, but to ask whether it is possible that some individuals referred to the services, as an initial point of contact could see somebody who is not a psychiatrist and if there was proper training in terms of being able to recognise the individual who needed psychiatric input, to be able to draw on that input appropriately but not to leave it as psychiatrists being the only gateway into support.

I think there is scope for exploring that without wanting to come down firmly in terms of a particular model.

Chairman, we need to chew on this point because one of the important recommendations we could make from this committee might be to look again at the whole make-up. If one cannot get the staff one is looking for, accepting it is not an option so we must find other options.

Dr. McDaid recommended that we look at the role. I would nearly say a worse word than that; I would say "stranglehold". It would suit the committee very much if Dr. McDaid could come up with an idea, plan or an organisational chart template she thinks would work. Would she be able to help us with that?

Dr. Shari McDaid

What I can commit to is that I will ask my colleague, Ms Kate Mitchell, to look at the approach from other countries that we can draw upon and that are more flexible.

That would be excellent. We would like to include that in the report as well.

I thank Dr. McDaid and Ms Mitchell from Mental Health Reform for all the work they have done. It has been a wonderful advantage for members to work with them. I commend everybody involved.

Twelve years have passed and we still have not come up with a plan. Twelve years ago, we should have been talking about training nurses and specialists, signing them up and giving them contracts even before they were qualified, thereby covering retention. In that period of 12 years we had the opportunity and we are still looking at the demographics of areas where accommodation is more expensive. We could have indexed linked wages and structures to that. The HSE is wasting so much money that perhaps it could have bought a couple of apartments and put the nurses into them, like the NHS does.

I wrote a synopsis from July 2017 to 2018 on the media coverage of the mental health services and how bad they are. Regardless of how much we talk about this, the days of talking about it must stop if we must start from scratch. It is now a couple of weeks before the summer recess and we should be coming back with a final report stating this is our plan as to what should be done and to start now. The synopsis makes for harrowing reading. Children with mental health issues are presenting at emergency departments, there are chronic shortages in mental health, more than 2,400 children are waiting for child mental health services and children are waiting 15 months to see a psychologist. According to the Ombudsman for Children, we are not delivering on the promises we made and it was noted that suicide claimed 70 schoolchildren in one year. Moreover, it has been reported that suicidal children face long waits to see specialist psychiatrists and that the ombudsman has called for increased mental health funding. Finally, while referring to being really burned out, a child psychiatrist resigned as conditions were not fit.

That is a brief synopsis of where we have come in one year in the mental health services. This gives members a broad picture how bad the situation is. No matter how much we talk about this, the days of talking have to stop. We talk about money and ring-fencing but we have to take the realistic approach. We have looked at the budgets over the years, including the additional so-called €35 million or perhaps €15 million with an imaginary €20 million on top that could not be spent. As the money could not be spent on recruitment, it was not spent. We should be ring-fencing this. The money that is being spent in the budgets now is only bringing us to a flat level as to where we should be. It has been well documented that we are short approximately 500 staff members in the mental health service as it stands and it will cost many millions to bring our staffing level to where it should be. We need an additional 500 staff members to bring us to what was envisaged in A Vision for Charge and we still would not have sufficient staff for the future needs. We need to think in terms of forward planning because within the next five years, we will lose 1,700 staff within the mental health service due to retirement and whatever. I love the honesty being expressed on the issue. I appeal to the two Ministers responsible to set out a realistic plan. If they will not invest in this plan, then as a Cork man once said, "Fail to prepare, prepare to fail." That is what we are looking at in the mental health services. I have no criticism of Mental Health Reform. We are not here to criticise. We praise people at times but inclusion and multidisciplinary teams get my goat at times because nobody knows how many are on each CAMHS team. It is like going out to a GAA match with 15 on one side and nine on the other and they are calling it two perfect teams. It does not work. I think the Government has to look at that. I do not care what way it is done; perhaps a pilot scheme in an area of high rates of suicide. We should be investing in these demographic areas and starting the pilot projects. The approach must be broad.

As an all-party Oireachtas committee, we genuinely get on most of the time but I appeal to the members of other parties to go back and set a marker, a map and a route to run both a proper health service and a proper mental health service. It goes back to plan A, that is, let us start by investing in training, by treating the people who work in the system with dignity and respect and let us not train our staff for export but to make them proud of the system. We need to become inclusive in order that regardless of whether one is a psychotherapist, a psychologist, engaged in art therapy and so on, one is part of the full team. We need to commit to building the full team. We must make the cake with all the ingredients that are listed on the bottom of the box because if one does not have all the ingredients, one will not come out with the cake one wanted to make in the first place.

As I do not think there were any questions there, I will move on to Deputy Corcoran Kennedy.

I thank Dr. McDaid and Ms Mitchell for their contributions this afternoon and wish to ask a couple of questions.

Last week, the director of the Healthy Ireland policy appeared before this committee. She talked about how the Healthy Ireland agenda is embedded in all the Departments, that there is an interdepartmental and whole-of-society approach and that taking care of one's mental health is a significant part of the approach. Today, the witnesses mentioned the Healthy Ireland policy in their contribution and the economic cost of €11 billion per year. Of course that is only the economic cost and it does not include the cost to individuals and their families. It became very clear from other contributors who attended our meeting last week that substance misuse is causing enormous mental health problems in this country. Do the witnesses think we are doing enough to convey how substance misuse damages one's mental state? Do the witnesses believe that people are aware that cannabis or alcohol inflict damage on one's brain? As for conveying the message that exercise and eating well is important, I believe that a focus on preventative measures will be crucial to our report because we want to keep people well in order that they do not need to access services and we want to empower and enable them.

I would like to know whether sufficient use is being made of psychotherapists in the system. Earlier reference was made to the number of psychologists and psychiatrists and whether sufficient use is being made of psychotherapists. Again, a point that arose in some of our engagements is that there are approximately 1,500 psychotherapists here and many of them are available to deal with whatever cases come before them.

Do the witnesses think the HSE should ensure art therapy is given a therapeutic role? I know that art therapy is really important, particularly to young people as it helps them to express themselves when they cannot express themselves verbally. The witnesses undoubtedly will correct me if I am wrong but I do not know whether there is a recognised position or proper grade attached to it. Art therapy is really important to many people who are dealing with mental health issues. Is there a recognised position? Such a position would be beneficial. While artists visit facilities on a freelance basis or whatever, without a proper grade they are in a vulnerable position. If we want to provide art therapy then we must mainstream the service.

Do the witnesses believe the facilities available across the country are adequate for what we want to provide to people? Recently we all decided to visit our local child and adolescent mental health services, CAMHS. Yesterday, I visited St. Fintan's Hospital in Portlaoise, County Laois. As I travelled towards the main entrance I thought that were I a 14 year old who was being admitted there, I would be completely intimated by it because the entrance looked fairly forbidding. I would feel intimidated even if I was an adult seeking care. Should we not spend more of the capital spend on these facilities to ensure they look welcoming? An awful lot of work has been done inside of the building but an awful lot of work remains to be done. I ask the witnesses to outline what standard these facilities should reach to better help patients.

Deputy Brassil mentioned the number of people who are available to deal with the cases. Is there an argument to be made for upskilling additional clinical nurse specialists who could intervene at a very early stage? Such specialists could also refer people, rather than have them spend time on a list waiting to be seen by a psychologist, psychiatrist, psychotherapist or whoever. Is there scope for such a position?

Dr. Shari McDaid

Mental Health Reform is part of the coalition that supports the Public Health (Alcohol) Bill. We certainly see the reduction in substance misuse as positive for people's mental health. We also would like to turn that on its head a bit and make the point that it may be that many people turn to substances and alcohol misuse because of an underlying untreated mental health difficulty and, again, that is where there is potential. If we can get people to easily access a low-level intervention much earlier then they may not end up in that situation.

Do the witnesses believe that we are doing enough educationally? Do they believe people know there could be negative outcomes if they overconsume or whatever?

Dr. Shari McDaid

I am not qualified to give a good answer on that and I hesitate to speak about things I have not really considered. The Deputy is right to say there is a link between substance misuse and mental health difficulties that is not discussed enough in the public domain, in both directions. We could do much more in that regard.

As for the question on the sufficient use of psychotherapists, earlier I stated we should vastly increase people's access to counselling and psychotherapy. We should not underestimate the potential for psychotherapy within the specialist mental health services as well. Some clinicians used to have the view that people with certain diagnoses were not appropriate for counselling and psychotherapy. I hope that we have moved beyond that view. Even if one has been diagnosed with schizophrenia, a schizo-affective disorder or a psychotic disorder, there might be real reasons one could also benefit from counselling and psychotherapy because one will likely have gone through real losses in one's life that one might need to explore. There are issues of having become more isolated and all kinds of emotional issues that might benefit from being explored. I say that as a layperson and not as a clinician.

I am really glad the Deputy mentioned a role for creative arts therapists because it is something about which we have not always been vocal. We would be very supportive of ensuring that a future mental health system incorporates and embeds the role of creative art therapists as part of the options available for people. The area was neglected in A Vision for Change and that situation should be rectified in any future mental health policy.

In terms of the facilities for mental healthcare, we know that there are problems with the facilities at all levels. I refer to community residences around the country that are not accessible for people although they have been people's homes for years. I agree with the Deputy when she mentioned day facilities and clinics that are not located in welcoming environments. Many people have told us that many inpatient settings in acute facilities need to be upgraded. My organisation would really support investment in that area and in ensuring there are respectful and welcoming environments for people in distress who seek assistance.

I agree with the Deputy that we should explore the upskilling of clinical nurse specialists as one of the options. We must consider all of the options and, therefore, should be open-minded. I ask all clinicians to be open-minded about considering a range of ways that we will need to adapt to higher demand. There is enough need to oblige us to call upon everyone who is able to provide different types of support and we must also be creative about drawing on their expertise.

I thank Dr. McDaid for her presentation and for her work over the years. She performs a very important role. One of the central themes of the presentation was broadening the scope of roles within mental health services to complement clinicians. What impact would it have on the service if we were to follow that? It picks up on what Deputy Brassil said about having a psychiatrist-centred service. If the scope of roles within the service were broadened, what would be the impact? I note also the importance of primary care as a means to deliver a proper mental health service for people. Dr. McDaid is looking for more resources for primary care. What type of resources does she advocate should be put in place at primary level to improve services?

I agree completely that CAMHS should be extended from five to seven days. Does Ms Mitchell have costings on that service extension nationally? It is one of those quick wins Deputy Neville asked for and something the committee could advocate in the forthcoming budget negotiations. I ask the witnesses to address those questions.

Dr. Shari McDaid

I see two major impacts from broadening the scope of the roles. The first relates to quicker access. We are very well aware in the community that one of our biggest problems is giving people timely access to care. The waiting list for CAMHS is the most visible aspect of that but there are other areas of the service where people cannot get access and where there are no lists to demonstrate that lack of access. That is one impact that would be very visible. The other impact would be in the context of choice. If there were a greater variety of roles, individuals attending services would have more choice in terms of the kinds of supports they would pursue in their recovery. That is very important from a human rights perspective because services should be in keeping with people's preferences for treatment. It is also something we know people want. We are all different in terms of what will assist our recovery. For one person, social prescribing will help in getting a prescription for a community group or a gym whereas one-to-one therapy will work for another person. For another person, it might be group therapy and for someone else it might be creative arts therapy. Someone else might need medication while another person might need regular support from a psychologist. To get philosophical for a moment, each person will have to shape his or her own recovery. That is the reality.

Mental health supports work best when they respond to the preferences of the individual. When people attend a service which is more one size fits all, one finds that they simply switch off. They may try to find supports on their own, but they may not be successful in doing so and their mental health may deteriorate. While it is positive that more and more people from all kinds of backgrounds are coming forward for mental health support because we are reducing the stigma, if more men come forward for counselling and psychotherapy when it used to be more women or girls, something tailored to them might be required. That is why we need to explore things like e-mental health whereby support can be accessed online by individuals who are not comfortable going to a clinic. As such, more choice is a potential positive impact. Ms Mitchell might be able to address the resources needed in primary care settings.

Ms Kate Mitchell

There are one or two quick wins. We could invest significantly in supports such as counselling in primary care and increase our investment in primary care psychology. However, we need to go a lot further. For example, GPs are trained in mental health, but there has yet to be an evaluation of the impact of that training. We need to look very closely at whether people are provided with the information they require when they see a GP or another primary care professional. Are they being referred to other community and voluntary supports in their local areas? We are looking for primary care professionals to be able to identify where there is a mental health difficulty, assess it and the need for referral to other services such as talking therapies as well as to refer appropriately to mental health specialists. The mental health system works best when there is appropriate integration and collaboration across the sector and the agencies within it. We also need to look at effective collaboration between primary care services and secondary services. For individuals who have been in specialist mental health services and hospitals and come back to the community or continue to avail of community specialist mental health services, it means also getting supports at primary care level. Primary care professionals should be adequately resourced to provide that support.

It completes the circle.

Ms Kate Mitchell

Absolutely. In terms of a couple of quick wins, there is huge demand for talking therapies at primary care level and that is somewhere we could invest significantly. Deputy Carey asked about the cost of extending services from five to seven days a week. The Minister of State with responsibility for mental health services has made a commitment to extend those adult mental health services which do not have seven-day cover to seven days a week and we know that is costing approximately €5 million. Given that there are fewer child and adolescent mental health teams, one speculates that the cost would be a little less albeit in and around the €5 million figure. Certainly, we are looking for 24-7 cover and that is just the first step towards it.

I thank Dr. McDaid and Ms Mitchell for attending. As ever, it has been an enlightening meeting. The Mental Health Parity Bill passed Second Stage in May - which was mental health month - with cross-party support. Unfortunately, a message was received from the Ceann Comhairle today to the effect that the Bill requires a money message from the Government. The Bill's provision mirror those which are already in operation in the UK. Could the witnesses address the importance of parity and having equality of supports? It does not mean that for every penny spent on physical health, a penny must be spent on mental health services. Rather, it requires that mental health has parity of esteem in the context of support.

I refer to what are sometimes called silos and to the gatekeeping that goes on, particularly in respect of mental health supports for schoolchildren. I have raised this with the Department of Education and Skills on a number of occasions. A report by Dr. Rosaleen McElvaney of Dublin City University's school of nursing and human sciences, which was funded by St. Patrick's mental services, was published recently. The report finds that primary schools are struggling to help suicidal children as young as four years of age. It reflects what I experience as I go around talking to primary school principals, teachers and other staff who are struggling to cope with very serious mental health issues which are starting to arise and which were perhaps not as common ten, 20 and 30 years ago. A great deal of it is to do with the Internet, what young children can access on it and the effect it has on them psychologically.

Much of this is meant to be addressed by the National Educational Psychological Service, NEPS, but there are issues with children being on the wrong waiting lists. Sometimes they are on a waiting list for a year and then are told they should have been on a different waiting list.

Will the witnesses comment on silos and the gatekeeping that goes on? CAMHS have little to do with community psychologists and they are treated separately. Will they comment on the disjointed nature of how we address the mental health needs of our young people in particular? For example, it was reported that there were 110 children under the age of four waiting over one year for access to community psychology services.

Dr. Shari McDaid

What do we mean by parity of esteem for mental health? The Deputy is correct that it is not all about money but money can be an indicator of intent. For example, in our thinking around the budget for next year, we recommend the Government meets its commitment on €55 million which the Minister for Health has indicated would be invested next year in additional development funding. We also recommend that mental health services would not lose out any more in the overall health budget. This is important because if it is not done, it sends a message that mental health is less of a priority than other parts of the health system.

Parity of esteem can be thought of in another way, namely equivalent outcomes and quality of service in mental healthcare to those expected in physical healthcare. For example, take the case of somebody receiving a diagnosis of cancer. Imagine if he or she went into our cancer services and was told that he or she will get chemotherapy but not radiotherapy because we do not have enough of the right disciplines to provide it. This would mean that they might not recover fully and may actually die but that is the best we can do. That would not be considered acceptable by the public. However, that is what we are doing every single day in our mental health services. We are saying that we do not have the adequate supports in place for someone in mental distress. In turn, this means that he or she may not recover as quickly or, in the worst-case scenario, he or she may lose his or her life. We are saying this is acceptable. We need to change that and start having a conversation about having the same standards of care and the same expectation of outcomes from mental health services as we do from physical health systems. That brings the parity of esteem issue to a different arena.

Silos are the bane of our system. We orientate illnesses around a certain category and then it becomes hard to bridge that category to another. Accordingly, we have services for children with disabilities and services for children with mental health difficulties. If one happens to be a child who is in both categories, then one is bounced from pillar to post rather than getting a coherent system.

We have advocated generally for a no-wrong-door approach. In other words, if one seeks help from a public service that is, broadly speaking, relevant, then it should be the service’s job to co-ordinate, integrate and find the supports one needs and then bring them to the patient. It should not be a case of the services saying that the patient is on the wrong list or not in our group and, therefore, it is up to the individual in need to navigate and find the services he or she needs. We have spoken about this in terms of individuals with mental health difficulties and substance abuse. If the committee were to endorse that principle on a higher level, namely, that the entire mental health system should adopt a no-wrong-door approach, then that could apply anywhere. That would drive services to have to be more integrated and to engage more with their peers because they would not be allowed to simply kick matters to touch. They would instead have to find and engage with the myriad services that exist. There are other specific examples on how to improve co-ordination.

Ms Kate Mitchell

There has been some recent movement on mental health and education. We have seen the introduction of a specific component on mental health and well-being in the new reformed junior cycle reform. That is to be welcomed. There is so much more we need to do in that space if we are going to address the whole issue of prevention and early intervention. We need to see mental health promotion programmes introduced at a much earlier stage at primary school level. We also need to see supports in senior cycle in secondary schools. If we are going to ask schools and teachers to provide that type of support, they need to be adequately resourced. We need to be looking at providing training and professional development for schools and our teachers.

In addition to prevention and mental health promotion, schools are well placed to be able to identify where there may be a mental health difficulty and refer a child or young person on. Again, they need to be well supported in that context. We know, for example, that schools in the UK can link in with child and adolescent mental health services and there are key liaison staff in specialist mental health services to provide that kind of support. They are parts of England which have mental health advisers who support schools in actually implementing mental health supports and services.

We really need to be looking at those types and models if we are going to push this forward.

I apologise that I was late for the presentation.

Several weeks ago the HSE reported that in south Dublin more women, young mothers, were dying of suicide than men. This is unprecedented. Usually, the ratio of suicide between men and women is 3:1. In south Dublin, including Clondalkin where I live, Ballyfermot and Tallaght, in 37 deaths from suicide, more than 50% were women. Many of them were mothers in their 20s and 30s. Obviously, socio-economic disadvantage played a part. Poverty, alienation, inequality and homelessness also have played a significant part in the past eight years where it has driven people to kill themselves. That is the reality. Will the witnesses comment on this? Is this a spike or a new reality? In the past six months, I know of four women who have died by suicide in my area. One would normally not hear of this. Poverty and social exclusion plays a large part in people's mental health.

There is a crisis of well-being in society, which is obsessed with consumerism. I do not say everyone is like that, but consumerism in a society where people are not being housed and are disadvantaged because of where they are from plays a significant part in how people perceive themselves. That can affect people's physical and mental well-being. Will Dr. McDaid comment on this point, particularly the figures from Dublin South-Central? Anyone would view them as startling. One suicide is bad enough, but this is a worrying trend.

Dr. McDaid might answer briefly, as Senator Devine has returned and has a couple of brief questions to ask.

Dr. Shari McDaid

I am not familiar with those statistics. They are worrying. It would probably be difficult for anyone to say at this point whether it is a trend. Suicide happens relatively rarely compared with the population as a whole, so it can be difficult to spot trends until after a few years have passed. We feel it is important that mental health be seen as an issue for the whole of our society, not just the mental health services, and that specific responsibility be taken by all Departments for their role in supporting and promoting mental health in the population. We have advocated for a "mental health in all policies" approach. The committee's endorsement of same would be welcome. Under it, every Department should consider how its programme of work impacts on people's mental health. This should form part of its decision-making. The same idea, albeit in a different format, was advocated by the independent monitoring group for A Vision for Change quite a few years ago.

It is widely accepted that non-clinical factors will impact on people's mental health and put them at risk. The Deputy mentioned a number of factors, including poverty. Relative deprivation is arising as an issue, as are insecurity of housing tenure, social isolation generally and unemployment in terms of how they affect people's self-esteem and self-confidence.

The mental health agenda has to be owned by every Department. When considering next year's budget, social welfare expenditure, the minimum wage or housing issues, part of the thinking must be whether the decision being made will improve people's mental health or have a negative impact. I would like this approach becoming integral to the way we think about mental health.

I thank Dr. McDaid, but we are running out of time. I am sorry. Senator Devine should be brief.

Apologies. I hope that I will not repeat anything. I welcome the witnesses and thank them for their presentation. I also welcome the representatives of the member organisations in the Public Gallery.

I will fly through my questions, and Dr. McDaid might ignore repeats. I have a difficulty with the oversight group for A Vision for Change. The Royal College of Surgeons in Ireland, the Psychiatric Nurses Association, PNA, and Mental Health Reform conducted a review, but it was kicked down the road as part of an oversight review, which is one of the issues we are trying to tackle. Will Dr. McDaid make a brief comment on this point?

Regarding the matter raised by Deputy Kenny about our area in Dublin South-Central, I got a response from the HSE about the increase in the female mortality rate there. The HSE believes that might just be ahead of the curve, which is frightening.

Would Mental Health Reform welcome online consultations?

I was chatting to Mr. Ray Burke of Mental Health Reform. The Mental Health Commission's answer to us about places it had claimed were unfit for purpose or habitation was not great. For example, it had been saying the same about St. Ita's Hospital in Portrane for ten years before it finally closed down. The commission's response was that there was nowhere else for the people there to go. Surely that should have been planned for during those ten years.

Three child psychiatrists have resigned in the south east. A part of that was down to the conditions of the infrastructure being used to deliver mental health services.

Perhaps Dr. McDaid has discussed the skills mix. Her submission refers to psychologists. I would include advanced nurse practitioners as prescribers. We often ask whether teams always need to be led by a child psychiatrist and whether the skills mix could allow for a multidisciplinary team - read the title to see what that means - to care for children, given the considerable shortage.

We still do not have the full facts on the outcomes and KPIs regarding the €1 billion that we are spending.

The Minister for Finance stated in a report today that 300 health service staff were being recruited per month. I would love to know who they are and whether they are front-line workers. The rate of retirements almost cancels out that number. There is no growth. This is one of the major calamities facing our health services.

The Senator is asking a load of questions.

"Well-being" is an important description of what most of us need if we are to grow and nurture ourselves. Early intervention was mentioned. Mental ill-health must be a less significant part and we need to build on well-being. Well-being must be owned by and be the responsibility of the community.

I apologise to the Chairman.

I thank the Senator. She made a couple of statements, but I will answer one of her questions. We discussed why teams have to be led by psychiatrists.

Mental Health Reform will provide us with a template of best practice in other countries. We will include that in our report.

One-line answers if possible, please.

Beat my timing, please.

Dr. Shari McDaid

Regarding the oversight group, the expert group requested that there be a review of A Vision for Change after seven years. It is important that there be a departmental review. We are supportive of the fact that the review can feed into this discussion and that the Oireachtas committee's role in setting a future vision, and the cross-party support for same, would be equally as important. We hope that they will have complementary roles.

When the Senator asked about online consultation, I imagine she was talking about online therapy or assessment.

The Minister of State, Deputy Jim Daly, was to introduce that.

Dr. Shari McDaid

He referred to telepsychiatry. We asked Mr. Kevin Cullen of the WRC to prepare an analysis of the various options on e-mental health. We can send that report to the committee. It shows a strong evidence base for telepsychiatry.

It is one of the oldest, longest-established digital or e-mental health initiatives. It is quite well established, particularly in the United States where they have had to cope with remote areas and providing for specific scenarios.

With regard to the Mental Health Commission not closing services down even when they do not comply, I do not know why that is, but I know it seems to be different from the approach the Health Information and Quality Authority, HIQA, takes. It is hard to make sense of not closing services down in light of the fact that the lack of compliance is around basic regulations and minimum standards. Services which are failing minimum standards are allowed to continue to operate. That has to be looked at. If that means stronger powers need to be granted from the commission, or stronger usage of those powers, that needs to be explored and dealt with. We have seen deterioration. We have not necessarily seen a straight improvement in services, even in things that do not cost money, such as care planning, where services might be okay one year but the next year might fail to comply, and the next year the same service might still not comply even though it had been a condition in the previous year. We do not get the impact from that regulation that we need so that people can have confidence in the services they use.

I was asked what the top three wins would be. The third one that came to mind is about increasing access to supports in the prison system. There is a huge need there which costs us greatly.

We have talked about investment in mental health, and the relationship between this group and the oversight group. One recommendation this group could make, even on an interim basis, that would be helpful is to ensure there is a costing of whatever comes out of the departmental review of A Vision for Change. It is not obvious from the terms of reference of the departmental review of A Vision for Change that there will be a costing of what it will take to implement it. Without that costing, we are concerned it would be less likely to be implemented. If this committee could recommend that a costing is done, that would be great.

We will ask for that directly of the Department. I thank Dr. McDaid and Ms Mitchell for being here today. If Ms Mitchell could help us with finding out what the best practice is abroad, it would have significant impact for us.

The issue of outsourcing keeps coming up all the time and, while we do not have time today, maybe Dr. McDaid and Ms Mitchell could help us with that also. We have many agencies across the country which can supply on demand yet the HSE does not tend to outsource. It seems to be the easiest solution of all, but maybe I am wrong. Will the witnesses give us their opinion on that and, if it was to happen, how we would go about it?

I thank the attendees in the Gallery also. Meetings are sometimes long and drawn out. It has nothing to do with me; it is all the members' fault for asking too many questions. All the information which the representatives of Mental Health Reform provided today will assist us in our final report.

The joint committee adjourned at 3.35 p.m. until 1.30 p.m. on Wednesday, 11 July 2018.