Mental Health Services: Discussion with Irish Mental Health Coalition and Amnesty International Ireland.

I welcome Mr. John Saunders, chairman, and Ms Caroline McGrath, director, from the Irish Mental Health Coalition. I also welcome Ms Mary Forde, legal officer, and Ms Fiona Crowley, research and legal manager, from Amnesty International Ireland. While Mr. Saunders and Ms McGrath have made presentations to the joint committee several times before, I draw attention to the fact that while members of the committee have absolute privilege, the same privilege does not apply to witnesses appearing before the committee. 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, by name or in such a way as to make him or her identifiable.

Mr. John Saunders

This is the third time the Irish Mental Health Coalition has made a formal presentation to the joint committee. The coalition comprises five organisations with a strong interest in mental health services: Amnesty International Ireland, Bodywhys, the Eating Disorder Association of Ireland, GROW in Ireland, the Irish Advocacy Network and Shine, formerly Schizophrenia Ireland.

The Irish Mental Health Coalition welcomes the Government's recent decision to reverse the proposed co-location of the Central Mental Hospital on the new prison site at Thornton Hall. The coalition was a strong advocate of such a reversal. It must be acknowledged that the committee's deliberations on the matter helped to bring about a change of opinion in the Government. I thank the committee for taking up the issue. However, there is still a need to prioritise a new building for the Central Mental Hospital. We support the Government's proposal to develop a new hospital on the existing site at Dundrum or on an appropriate greenfield site.

Since our last appearance before the committee, there have been several developments. The report of the Inspectorate of Mental Health Services, the third report of the independent monitoring group to oversee implementation of A Vision for Change and our own report on it have been published. The unfortunate report of the inquiry into care and treatment practices in St. Michael's unit and St. Luke's Hospital, Clonmel has also been published.

The recent report of the Inspectorate of Mental Health Services stated, "From the broader perspective of the quality of care and treatment, little has changed, despite the introduction of A Vision for Change and the reorganisation of the delivery of health services under the Health Service Executive." It continued:

People with serious mental illness requiring hospitalisation are in many cases still in accommodation in 19th century buildings unfit for purpose ... Over 200 children have been admitted to approved centres for adults in 2008. This practice is inexcusable, counter-therapeutic and almost purely custodial.

These conditions are further complicated by the current economic climate. There has been a concerted effort to reduce costs across the entire Health Service Executive where bottom-line figures are the determining factor in the services provided.

The coalition was disturbed by the report of the inquiry into care and treatment practices in St. Michael's unit and St. Luke's Hospital, Clonmel. The report suggested this was the direct outcome of poor resource allocation in the past 20 years, poor management practice and co-ordination of services. The coalition welcomes the Health Service Executive's commitment to reforming mental health services in the Tipperary region. By 2010, it will have turned around services from being custodial-institutional to community-based and person-centred.

The issues raised in the Clonmel report are the tip of the iceberg. The recent report of the Inspectorate of Mental Health Services suggested practices and service problems found in Clonmel could be found in other parts of the country. These include poor physical buildings, overcrowding, inappropriate staff in place to provide the therapeutic environment required, cost-cutting at an alarming rate which results in people being in unsafe and non-therapeuitc services. With the Health Service Executive looking at bottom-line figures, there has been a large effort in contracting services to make resources go as far as possible. The new and more desirable community-based services outlined in A Vision for Change are being contracted to support a centralised, outmoded residential service. For example, people attend day care services from their own home in their local community, and the amount of activities, staff and even physical buildings available at these centres is being curbed. This is happening to an extent that people are often left in day care centres without therapeutic or recreational activities, and without the type of staff necessary to provide support and guidance. Community mental health nurses, who traditionally should work in the community and visit people in their own homes, are being asked to curb their activities simply to reduce expenditure. In other words, community mental health nurses who might work in a rural environment are being asked not to travel from A to B because it will incur an additional mileage expense. This is quite simply ridiculous, because the whole function of a community mental health nurse is to provide a domiciliary service in one's home.

By definition, sitting in an office in some health care centre is not providing a community mental health nursing service. People in many parts of the country, particularly those in rural areas, are not being seen by community mental health nursing staff as often as they should be. Inevitably, this will lead to a deterioration in the service provided for them, and will inevitably lead to an increase in readmission of people to centralised residential services. From research abroad and at home, we know that if people do not get the type of adequate community based service they need, they will eventually become critically ill and require readmission to a centralised residential service. In the long term, there is no good in curbing community based services in favour of centralised hospital services.

The embargo in place at the HSE for two years means that vacated posts are not easily filled. If essential posts in nursing, social work and other types of care become vacant, a service does not exist for that period, be it maternity leave, holiday leave or retirement. That inevitably means services to people will diminish over time. It is a scatter gun approach, because nobody could predict the different types of leave that occur, and due to the need of the HSE to adjust its bottom line figure, it is forced into a situation where all leave is automatically not covered until further notice.

Ms Caroline McGrath

I will pick up on the issue that Mr. Saunders mentioned regarding the implementation of mental health policy and A Vision for Change. I will also look at some of the challenges of maintaining and implementing reform in the current economic climate. The position of mental health services in a time of recession is particularly acute. Mental health services, just like access to debt management and unemployment assistance, is one of those services that must increase in times of economic difficulty. That has been borne out anecdotally but also in emerging information on mental health services. Towards the end of last year, voluntary groups like Aware and the Samaritans were already recording increases in demands for their helpline services.

The Health Research Board publishes annually on the level of in-patient treatment, and its figures for 2007 showed the first increase in in-patient numbers for 26 years. That is particularly worrying in the context of potentially increasing demand towards the end of that year. It is also worrying in the context of that mental health service, in which we were expecting and seeing reform towards community based services. In times of economic difficulty, mental health services are a vital public service that need to be increasingly supported. This has been acknowledged by the World Health Organisation. It has been acknowledged practically by our neighbours, as the British Government invested an additional €175 million at the start of the year in mental health services, recognising that an increased demand on services was an inevitable part of the economic downturn.

Notwithstanding the current economic difficulties, the fact is that mental health services are under-resourced. The obvious quote is that 7% of health budgets are allocated on mental health. The comparative figure for England is 12% and for Scotland is 18%. Regardless of the economic position, this is the reality. Having said that, there are opportunities to use more effectively the resources that are provided to mental health. One example is the extent to which historically, the mental health services have provided housing for people who no longer require inpatient treatment, due to the absence of adequate local authority, social or other housing. It is anticipated that about 3,000 places in 400 residences are supported by mental health services staff. That provision should more appropriately be met by a local authority as part of its housing remit. Critical monetary and staff resources from the mental health services are tied up in those residences.

Many committee members will be aware of recent staff shortages in the Central Mental Hospital, which have led to a need to cease admissions. There is clearly an issue with staffing and resources at the hospital, but there is also a particular problem with the drafting of the Criminal Law (Insanity) Act 2006, as persons in the Central Mental Hospital deemed by the review board as fit for discharge are currently not being discharged, in the absence of any means of enforcing conditions on that discharge. This issue was highlighted as early as November 2008, and it requires an amendment to the Act that would free up spaces. It is a waste of resources that could easily be addressed. It is another example of how acute mental health resources could be more effectively managed.

There is an ongoing issue with trying to ensure that the money being used and the reforms agreed in A Vision for Change are being accounted for and implemented. The IMHC has a number of concerns about this. Implementing A Vision for Change, which is the national policy on mental health, requires an implementation plan that is fit for purpose. There was an implementation plan published in February 2008. It was clearly inadequate, and the HSE was asked to develop a further implementation plan for the period of the strategy. That plan was published earlier this year and in our view, it is inadequate in respect of basic elements of accountability. A Vision for Change includes about 250 recommendations. In spite of being ongoing for three years, the implementation plan indicates that all of those recommendations will be fully implemented by 2013. If we are already three years behind, where is the prioritisation? What are the resources required to deliver that are not indicated? What are the human resources? How will we have the staffing? Where is the man power planning? What is the time line for each activity? How will it be implemented and what will it cost? None of those questions were answered in the implementation plan and those basic standards are not in place. It is our respectful submission that we cannot possibly conceive of a successful implementation of the reforms proposed under A Vision for Change, and the tracking of those reforms, if there is no implementation plan to begin with which adheres to basic levels of accountability. The Department of Health and Children and the Health Service Executive are just two of the players in implementing A Vision for Change, yet no other Department has published, or indicated its intention to publish, an implementation plan outlining its responsibilities and how it proposes to fulfil them. The strategy cannot be implemented by the Health Service Executive alone.

In regard to accountability for the investment of mental health funding, the issue of diversion of funding in 2006 and 2007 has been rehearsed by the committee. The reality now is that there is virtually no development funding to be diverted. Notwithstanding that, we do not know how existing funding for mental health is being used, and there is no linking of mental health funding to outcomes in the health service. The issue of the draining of funding away from mental health services is something of a moot point in the absence of development funding, but there remains a concern regarding the ring fencing of resources, particularly resources that may accrue from the sale of lands. We acknowledge that the Minister has consistently committed to ring-fencing those resources. However, we are concerned that the Health Service Executive implementation plan indicates a lack of certainty in this regard. Comments from the Department of Finance certainly seem to indicate there is question mark over such ring fencing.

Ultimately, all our comments relate to existing levels of funding, which is not to detract from the need for enhanced funding. One of the issues of particular note for us is the point that reforming mental health services is not merely a matter for the Health Service Executive and the Department of Health and Children but requires a cross-departmental approach. The costs and potential savings arising from investment in mental health services are met and gained in different Departments. In regard to housing, for example, the capacity to address resourcing at a cross-departmental level would be a welcome development. There are savings to be made where good mental health services are in place. For example, persons in receipt of social welfare benefits may no longer require those benefits if they are supported in their recovery. That constitutes a direct saving but one which is never costed within the budgeting for mental health provision. We would like to see a move towards some mechanism for managing mental health expenditure and investment at a cross-departmental level.

I apologise for interrupting Ms McGrath. I remind her that we intend to allow time for questions.

Ms Caroline McGrath

My apologies.

We are very interested in what Ms McGrath is saying but must allow time for the delegates from Amnesty International Ireland. I invite Ms McGrath to make her concluding remarks.

Ms Caroline McGrath

Several recommendations are set out at the end of our presentation document.

That has been circulated to members. I invite the delegates from Amnesty International Ireland to make their presentation.

Ms Fiona Crowley

We welcome the opportunity to address the joint committee on the need for a comprehensive review of the substance and operation of the Mental Health Act 2001. Amnesty International Ireland has been campaigning for improved mental health services since 2003 and is an active member and supporter of the Irish Mental Health Coalition. In May of this year, we launched a new phase of our campaign, designed in partnership with people with direct experience of mental health services. Reform of the Mental Health Act featured strongly in what people with mental health difficulties wanted us to focus on for the next two years. They want an Act that complies with the right to be treated in the least restrictive environment and with the least restrictive or intrusive treatment.

There is insufficient time to outline the provisions of the Act that are problematic from a human rights perspective, but they mainly relate to involuntary admission and involuntary treatment. Part 4 of the Act makes so many inroads into the general rule that a person should have the freedom to consent to treatment as to render it practically meaningless for persons detained under the Act. While the Act's provisions are modelled broadly on the 1991 United Nations principles for the protection of persons with mental illness, those principles have long been considered out of date in that they adopt an overly restrictive and medicalised approach to involuntary treatment and detention. The new UN Convention on the Rights of Persons with Disabilities, which entered into force in May 2008, supersedes those principles and goes much further in protecting the fundamental rights of persons with mental health difficulties. The provisions in the Mental Health Act relating to children are incompatible with the rights enshrined in the UN Convention on the Rights of the Child. For instance, under the Act, children under the age of 18 can be admitted and detained against their will despite being competent to make their own decisions, since their voluntary or involuntary status depends solely on their parents' consent.

Although a significant improvement on the Mental Treatment Act 1945, the 2001 Act is out of step with human rights standards. The time has come for open and frank debate as to how Ireland should deal with the issue of involuntary admission and treatment of persons with mental health difficulties. More broadly, the entire Act should be opened up for debate and reform, including the powers and functions of the Mental Health Commission and the inspectorate. Consideration should also be given to how the Act might be expanded to serve as a driver for reforms envisaged in the Government's stalled mental health policy, A Vision for Change.

The Department of Health and Children published its first review of the Act in May 2007, as required under section 72. This first review was limited in scope to the operation rather than the substance of the Act. Even at that, many areas of serious concern were dealt with only cursorily. The Department conceded the less than comprehensive nature of this review and also confirmed the need for further consideration of the Act, including the matter of informed consent to treatment. We welcome its commitment to undertaking a detailed review within five years of the full implementation of the Act, that is, on or before 1 November 2011. The Mental Health Commission also published a review in 2008. However, its review was limited under statute to the operation of involuntary admission procedures in Part 2 of the Act.

In essence, therefore, we are concerned that the Department must not adopt a similarly narrow approach to the next review of the Act. If that review is to yield meaningful analysis and reforms, its scope must be broader than the operation of the Act. A comprehensive and substantive review is called for, line by line and section by section. Its provisions, and their implementation in practice, must be examined against the Act's object and purpose. They must also be reviewed against international human rights standards, particularly the UN Convention on the Rights of Persons with Disabilities. There have been several developments since the Act was drafted which make the legislation out of date from a human rights perspective, including the enactment of the European Convention on Human Rights Act 2003 and recent case law from the European Court of Human Rights. The human rights framework itself has continued to evolve since the Act was drafted, particularly through the adoption of the UN Convention on the Rights of Persons with Disabilities, which Ireland has yet to ratify. If we are serious about our intention to ratify, and thereafter comply with, the convention, then it must be the benchmark against which the Act is reviewed.

We also have concerns regarding the timing of consultation plans. While Amnesty International Ireland understands that the Department intends to commence its review of the Act in late 2009 or early 2010, it is imperative that this is not long-fingered. It must be commenced at the earliest opportunity and must not be a rushed or cursory process. If the UN Convention on the Rights of Persons with Disabilities is to be the benchmark for the review, the Department must avail of human rights inputs and expertise. It is important to note that the disability convention is in its infancy and that the relevant UN committee has yet to issue comments clarifying the implications of the convention.

A transparent consultation process must be entered into as soon as possible. In particular, there must be meaningful engagement with those with mental health difficulties. We must see a clear process and timetable from the Department as soon as possible. Amnesty International Ireland has itself begun a comprehensive review of the Act, taking into account leading expert opinion and the approach adopted in other jurisdictions on the implications of the provisions of the disability convention. We shall submit our report to the Department and the committee in due course.

I will now hand over to my colleague, Ms Mary Forde.

Ms Mary Forde

The review of the Act must also consider what additional protections may be afforded. The majority of the Act's provisions, such as those relating to informed consent to treatment, apply only to persons involuntarily detained under the Act. Only 10% of those availing of inpatient services and none availing of community-based services benefit from any of the, albeit inadequate, safeguards set out in Part 4. Further provision might be also be made to build an advocacy and complaints process into the Act so that appropriate mechanisms are in force for the submission, investigation and resolution of complaints.

The review should also look at the wider mental health services environment in which the Act operates. Lack of implementation of the recommendations of A Vision for Change, particularly those providing for the establishment of multidisciplinary community mental health teams, has lead to continued over-reliance on inpatient care. This has been noted by the Inspector of Mental Health Services.

Ms Fiona Crowley

I will conclude the presentation as Ms Forde is struggling with a sore throat.

We also firmly believe the review of the Act must be set in the context of wider mental health services provision. This issue is highlighted, in particular, by the November 2008 High Court case of SMv. the Mental Health Commissioner and others. The context was that in a case in which a person was deprived of her liberty, the opinion of the treating psychiatrist was that the person in question would not have required involuntary admission and detention had the required supervised accommodation been available. Consequently, it was in the light of the unavailability of such an alternative that the court had to decide not to order her immediate release.

The Department need not and should not await the 2011 review report to introduce amendments. For instance, it already has acknowledged that section 59 requires amendment. It allows a programme of electroconvulsive therapy or medication for a period in excess of three months to be administered to an involuntary patient, where that patient is unable or unwilling to give consent. A person being unwilling means he or she has the capacity to make a decision to refuse treatment and has made such a decision, which should be definitive and determinative of the issue. In its review of 2007 the Department recommended that a monitoring group be established to identify any difficulties with the Act as they arose and examine solutions. While this group was to include representatives from the Department of Justice, Equality and Law Reform and other statutory bodies, we have yet to see amendments in this regard being tabled.

In summary, Amnesty International seeks the support of the joint committee in a number of areas. We urge it to recommend to the Department that its review of the Act be commenced at the earliest opportunity. It should provide for an early commencement of a transparent consultation process in order that there is sufficient time for meaningful engagement with relevant stakeholders, not least of whom are users of the services. Second, Amnesty International seeks the committee's support in calling on the Department for the review of the Act to be substantive and not simply operational in order that the Act's provisions and their implementation will be comprehensively assessed against human rights law. Third, we urge the committee to engage in discussions on the issue of informed consent to treatment. The involuntary treatment provisions of the Act are perhaps the most difficult and controversial. In June 2008 it was suggested in a Seanad debate on the Mental Health (Involuntary Procedures) (Amendment) Bill that the issue of informed consent to treatment be discussed at the joint committee and that it should hold hearings on the issue. This recommendation was echoed by the Minister of State with responsibility for disability and mental health, Deputy Moloney. Fourth, Amnesty International urges the committee to recommend that the Department not wait until the end of 2011 before amending certain glaring inadequacies in the Act. It might also follow up on the recommendation from the Department's review that a monitoring group be established.

Amnesty International thanks the joint committee for providing it with the opportunity to make this presentation. It is worth noting that the forthcoming review will be of international significance, given that it will take place during the early life of the disability convention. It is an opportunity for Ireland to aim to be a model worldwide for how democratic states which value human rights should approach laws relating to mental health. The committee can play a key role in ensuring we seize this opportunity to consider how Ireland's legislative framework could be improved and expanded to ensure the human rights of people using mental health services are respected, protected and fulfilled at all times.

I welcome the delegates and thank them for their presentations. While members have considered this issue repeatedly, things are not changing and there is no development. Although there is a commitment to policy, there is no commitment to investing resources. It is interesting that the independent monitoring group's report on A Vision for Change examined the absence of clear and identifiable leadership. I have only one question for the delegates. Although the Minister of State, Deputy Moloney, has informed me that he intends to appoint a dedicated leader to implement A Vision for Change, this appears to be a moving target. Two weeks ago he told me the appointment was imminent. Both the person and the appointment are crucial to the implementation of A Vision for Change. Perhaps the delegates know what the current position is because it certainly is hard for me to find out. Their presentations speak for themselves and I have no questions on them.

I apologise as I must leave to attend another meeting.

I welcome the delegations and will revert to Ms McGrath's presentation. Everyone accepts that if the implementation plan is three years behind schedule, it will not meet its target date and that it would be foolish to even consider the possibility. However, is there an indication of a likely timeframe for the plan? My question is whether it will be a 12-month or 24-month period.

I also wish to be associated with the welcome extended to both groups. As I noted, it is important that the joint committee holds such meetings. I applaud and compliment both organisations on their work and the ongoing contact all other colleagues and I have with them. I made a point earlier that is relevant, namely, that each group which comes before the committee will have a sense of priorities and ideas, particularly in a time of recession, as to where resources should go. It is important that all groups, certainly including those represented by the delegates, continue to compete strongly in that regard.

I try to support the work of my colleague, Deputy Neville. I hope he does not mind me saying so as it might get him into trouble, but it is important to support what has been done. A number of members have taken a particular interest in many of these issues. Without wishing to distract attention from the two excellent presentations, I had intended to raise the need to ascertain what was happening in respect of the development of the Central Mental Hospital because I have read in the newspapers that it is not proceeding at Thornton Hall, as members had understood. While considering these issues, I wonder what is the position in that regard.

It is important that all groups should continue to compete and the delegates have raised particular issues. While I do not wish to be in a "Groundhog Day" scenario, I stated previously my interest in having delegations that make presentations to the joint committee return before it, perhaps a year later, to tick off what has been achieved. There are many challenges in respect of mental health issues and there always will be issues with which one must cope. I will pose the same question to the delegates, namely, in a perfect situation what would they wish to see achieved on foot of their contacts with colleagues, all of the parties and the Oireachtas joint committee?

I welcome both delegations. Mr. Saunders's description of how a mental health community nurse was informed she was obliged to cut back on travel shows how preposterous it is for cutbacks to be made without considering outcomes. A central point of his presentation was the need to measure outcomes when implementing A Vision for Change, in particular. I refer to the Irish Mental Health Coalition's suggestion of a ring-fenced percentage. I believe a figure of 10% was mentioned in the briefing document. Ultimately, will this be necessary to secure the requisite level of funding? This figure, together with a number of others, appears to be easy to cut. It is one of the target areas of expenditure that always appears to be hit whenever there is a shortage. Do the delegates consider this to be essential in terms of making progress?

I congratulate the Irish Mental Health Coalition on its success regarding the Central Mental Hospital, as its campaigning in this regard was extremely important. I refer to the meeting in the Mansion House at which Mr. Jim Power provided an excellent presentation on how one could do it differently. What is the coalition's view of the hospital's location? Should it remain in Dundrum or should it be located elsewhere?

As for Amnesty International, the joint committee welcomes its expertise in respect of the specific detail regarding this issue which is complicated. Last week Oireachtas Members were obliged to deal with an entirely new section in a completely different Bill that pertained to transferring people involuntarily who had been detained. Clearly, balance of human rights issues arose in that regard that were sprung on members. As time is available in respect of the review of the Act, members certainly will welcome availing of the expertise of Amnesty International in this regard.

The delegates obviously have raised issues of fundamental concern to the joint committee. Members are united in wishing to prioritise issues pertaining to mental health and for some time have been anxious to have discussions with the Minister of State, Deputy Moloney, on the implementation of A Vision for Change. One thing we definitely can do is to bring forward the date of that meeting as a matter of urgency to address the concerns the delegates have raised. They should take on board the points raised by members. Who wishes to respond first — Ms Crowley or Mr. Saunders?

Mr. John Saunders

I will respond specifically to Deputies Neville and O'Connor; my colleague will address some of the other issues raised.

It is clearly set out in A Vision for Change that a directorate of mental health should be established to oversee implementation of the strategy. However, this has not come to be, despite the protestations of groups such as ours and many others and the pressure exerted from the Department of Health and Children. I understand the HSE's resistance stems from the notion that a directorate does not fit into the overall transformation structure being devised in the post-health board era. My latest understanding is the HSE has agreed to the appointment of a person to oversee development of A Vision for Change. We would call that person a director, but the HSE is using slightly different language. I have not yet seen the job description and so on for the post, but I understand the process is ongoing and that someone will be appointed within the next couple of months.

Mr. John Saunders


When we discuss the establishment of a directorate, I have visions of a large office, many staff and much administration. What we need is an individual to lead the process in the same way as Dr. Keane.

What we want is a Tom Keane.

Mr. John Saunders

What we need is one person charged solely with implementation of A Vision for Change and who has the necessary authority to ensure it occurs. The latter is the important element.

It is authority, not people, that the director needs.

Mr. John Saunders

I understand there will be an announcement. I do not know the details surrounding the appointment of the person concerned, except that he or she will be appointed from within the HSE, which is the HSE's business.

Regarding the retraction of services mentioned by Deputy O'Connor, the core issue is that in these times of hardship the HSE is going for soft targets and reducing community services to shore up centralised residential services. This is a reversal of the policy of A Vision for Change which requires that we close down centralised outmoded services and provide community services. Euro for euro, the outmoded centralised services are more expensive. As such, the HSE is doing two things, namely, reversing policy and costing itself more money in the long term.

The Government has clearly stated several times during the past two years its desire to provide a new central mental hospital. We support this desire fully, although the location of the hospital was at issue in recent years. We fully support the Government's statement on providing a new hospital on site or an appropriate greenfield site, but the location has yet to be determined. I have heard nothing about a plan B.

Ms Caroline McGrath

An implementation plan has been approved and was brought before the board of the HSE in April. It sets out each recommendation and conducts some analysis, for example, of current staff levels across the four HSE regions and identifies where the deficiencies are. It has been identified that more than 1,000 new whole-time equivalent posts will be necessary to implement A Vision for Change. The plan analyses which of the old hospitals must close and what the infrastructural costs will be within a range of several hundred million euro. Of concern to us in the plan is the level of implementation of individual recommendations. Behind each recommendation is a date. For example, 2013 is the date set for the development of a specific centre to deal with eating disorders among young people. That is as much as we know of the implementation plan. Clearly, the centre will not just be established in 2013. There is no budget, resources allocation or indication of how many staff will be required.

Deputy O'Sullivan has asked whether ring-fencing to a figure of 10% is the way to go. When the Mental Health Commission examined the economics of mental health services, its report suggested a figure of 10%. This needs a response. Why is a figure of 10% appropriate and what outcome would be achieved? There is no merit in identifying a target and achieving it, unless we know what the reform plan will be. We do not want additional funds for old services that do not work, which would be a waste of public funds. Difficult decisions are not being made. We cannot stand over this. We must face reality and, through prioritisation, be honest about what is achievable. Then we must hold ourselves to account at Government, institution, service and NGO level on why we are not achieving these priorities, if that is the case.

The retention of capital within the mental health services is of concern. If the Government and Professor Drumm did anything, it was to confirm over and over again that capital would remain within the services.

Mr. John Saunders

I will clarify the matter. At the time of introduction of A Vision for Change the Minister for Health and Children, Deputy Harney, and various Ministers of State supported the ring-fencing of moneys raised from the sale of land, buildings and so on. The HSE also confirmed that desire, but the sticking point is that officials in the Department of Finance have stated there can be no guarantee that moneys raised will be returned automatically to mental health services. The money must first revert to the Department of Finance and a case must then be made for their return. While Ministers and Ministers of State might want to ring-fence moneys raised, the Department of Finance has not made a clear statement.

Is the Government in charge?

Who are the paymasters?

When the Minister makes a statement before the committee, it is Government policy, given the principle of Cabinet collective responsibility. While the mandarins in the Department of Finance might say something, they must move forward on the basis of public policy.

The 2008 January report strongly reiterated that all finances from sales should stay within the sector.

Mr. John Saunders

Some €42 million raised from the sale of land at St. Loman's Hospital in Dublin and part of St. Brendan's Hospital is with the Department of Finance. The HSE would like to see the money go towards the development of mental health services. According to the Minister of State, Deputy Moloney, it should be invested in the services, but it remains with the Department of Finance and there are no plans to have it to be transferred.

We must take up the matter with the Minister of State when he attends.

Ms Fiona Crowley

I wish to address two important points. Deputy O'Connor asked what the committee should do when it was faced with what appeared to be competing demands for increased resources. We are not saying mental health services need more money; rather there is a need for accountability. A Vision for Change was devised in a different economic environment, but the bulk of what was required for its implementation was to be provided through the reallocation of existing resources. However, we continue to invest in the least cost effective and most expensive patient care options. As my colleagues in the coalition mentioned, the conditions in inpatient services are frequently not therapeutic. Compare the number of mental health teams for children with the number of children admitted to adult inpatient facilities every year. The latter is a more expensive option that the children concerned probably do not need and has been described by the Inspector of Mental Health Services as being purely custodial and not therapeutic. We want accountability and transparency as regards whether the money is going towards the most cost effective solutions, which does not seem to be the case. We need a resource allocation model. Amnesty International Ireland has engaged a consultant, as NGOs need to suggest solutions, not just identify problems.

Deputy O'Connor has asked what we hope to achieve. At the very least, we hope there will be transparency and predictability. There are conflicting numbers for how many mental health teams for children are in place. We believe the number is approximately 50, even though in 2006 and 2007 the HSE was supposed to have 55 by year end. Four weeks ago, in response to a parliamentary question, the Minister for Health and Children said there would be 69 by the end of this year. That is impossible. We need a HSE implementation plan that sets out, year on year, what is deliverable with existing resources.

Regarding Deputy O'Sullivan's question on the Mental Health Act, we are happy to provide expertise on the technical aspects of the Act. What happened with the recently passed Health (Miscellaneous Provisions) Bill was typical of the Government's approach to legislation, which tends to be reactive and piecemeal, reacting to a crisis or court case. The review of the Mental Health Act must be proactive. Miscellaneous provisions legislation never presents the ideal opportunity for introducing amendments. A number of legislative provisions could save money such as section 13 of the Criminal Law (Insanity) Act which would allow people to be discharged from the Central Mental Hospital. This simple amendment, which the Government knows it should make, would free up places, but it tends not to be a competing priority. This illustrates the need for an early commencement of the review of the Act in order that we might use one opportunity to get it right.

I thank Ms Crowley for dealing so comprehensively with the questions raised. We will return to the subject in a meeting with the Minister of State. We will take on board the challenge thrown down by Ms Crowley and see what we can do to assist. I thank the representatives of Amnesty International and the Mental Health Commission for attending. I ask committee members to remain to take care of some housekeeping business.

The joint committee went into private session at 5 p.m. and adjourned at 5.05 p.m. sine die.