Traveller Mental Health: Discussion (Resumed)

I welcome members and viewers who may be watching this meeting on Oireachtas TV to this meeting of the Joint Committee on Key Issues affecting the Traveller Community. I welcome our visitors in the Gallery who have come to watch proceedings in person. The purpose of today's meeting is to continue deliberations on the topic of Traveller mental health.

We will meet the Minister of State, Deputy Jim Daly, and officials from the Department of Health. We will meet Senator Joan Freeman, who has advised us that she has to leave because of a clash of commitments, but her commitment to this issue is noted and I thank her for giving us a little bit of her time this morning. We are joined by witnesses from Mental Health Reform, the Clanwilliam Institute, the HSE, and Dr. Brian Keogh from Trinity College Dublin.

We welcome everybody here this morning. It is the third meeting of the committee, each of which have focused on mental health. Following the meeting on 24 September, last week we heard powerful and stark testimony from Martin Reilly. He gave a harrowing, first-hand account of suicide and its impact in his life and on his family. Mr. Bernard Joyce of the Irish Traveller Movement reminded us of the statistics and the rates of suicide among Travellers from the well-respected and authoritative 2010 all-Ireland Traveller health study. Suicide among Traveller men occurs at a rate seven times as high as among the general population and the rate among Traveller women is six times as high. The Irish Traveller Movement estimated 30 deaths by suicide to the end of August. That estimate was not made lightly.

Dr. Brigid Quilligan of Kerry Traveller Health Community Development Project spoke of the hurt and causes of Traveller mental ill health, enduring long-standing racism, hate speech, prejudice and discrimination towards her community. Ms Minnie Connors from Wexford also shared her personal experiences of everyday racism, hate speech, prejudice and discrimination in her life, and its effect on the mental health of her family and friends.

Mr. Patrick Reilly of Pavee Point, who is present in the Gallery, spoke of the everydayness of suicide in his community and brought attention to the State's response and cuts that still have not been reversed.

Last week we heard from Thomas McCann of the Traveller Counselling Service, echoing and amplifying testimonies from the 25 September hearing. He also referenced the 2010 all-Ireland traveller health study, the shocking findings of which have been ignored. He spoke of indifference and inaction by the State in the face of the facts. He spoke of the limitations of goodwill and the need for real political will and leadership. He called for three specific actions, namely, the establishment of a national Traveller mental health steering group; the development of a national Traveller mental health strategy; and allocation of necessary resources to ensure its implementation.

Ms Sandra McDonagh from the Offaly Traveller Movement gave a stark account of mental health among Travellers in that county and the devastating effect on her community. She spoke of a colleague who had lost eight first cousins to suicide. She echoed Thomas McCann's observation of indifference and asked the Government how it can watch her people suffer and die, and do nothing about it. She outlined an approach in Offaly, entitled "Travelling to Well-being", which is showing positive results and should be supported or replicated.

Ms Bridget Kelly from the Galway Traveller Movement said that addressing the mental health needs of her community should be a priority. She drew committee members' attention to "just therapy" an approach developed in New Zealand.

Ms Niamh Keating spoke of how mental health issues were affecting Travellers in west Limerick. She referenced a recently completed baseline study among Travellers in Clare. Findings include 94% of people surveyed saying they had experienced discrimination and 87% saying they worry about discrimination some or most of the time. That anxiety can be the context for mental ill health. She also brought the members' attention to a peer-to-peer youth mental health strategy having a positive impact. However, like all such initiatives, it needs to be put on a firm funding footing and adequately resourced to do its job.

Ms Maria Carnicer from Exchange House Ireland talked about the social determinants of good mental health, including access to safe living conditions, adequate housing, educational opportunities and meaningful engagement in work and society. She said that 90% of the people seeking support from Exchange House Ireland had experienced trauma. She spoke of the need for culturally competent front-line mental health services. She referenced the approaches of eye movement desensitisation and reprocessing, EMDR, and contextual-conceptual therapy, CCT, which notes that feeling suicidal is not a mental illness, but an attempt to create a life without intense emotional pain. I thought that was a very interesting observation and worth noting.

Given the prevalence of suicide among Travellers, we may be able to reflect that the Traveller community is experiencing that intensity of emotional pain individually and collectively. That is why we are here today.

I welcome the Minister of State, Deputy Daly, and officials from the Department of Health. We are also joined by Senator Joan Freeman, Ms Kate Mitchell from Mental Health Reform, Dr. Brian Keogh from Trinity College Dublin, Dr. Aileen Tierney from the Clanwilliam Institute, Mr. John Meehan and Dr. Siobhán Ní Bhriain.

In accordance with procedures, I am required to draw attention to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. They are directed that only evidence connected with the subject matter of these proceedings is to be given. They are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him or her identifiable. Members are reminded of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside of these Houses, or an official either by name or in such a way as to make him or her identifiable.

I remind members and witnesses to turn off their mobile phones or switch them to flight mode as they interfere with the sound system and make it difficult for the parliamentary reporters to report the meeting. It also adversely affects television coverage and web streaming. I also wish to advise that any submissions or opening statements that witnesses have made to the joint committee will be published on the committee's website.

Because the Minister of State and Senator Freeman need to be elsewhere later, we will pause after the first two statements and take questions and then will continue with the others. I invite the Minister of State to make his opening statement.

I thank the Chairman for the invitation to come before the committee. I welcome the establishment of the committee and look forward to seeing its work unfold over the coming months.

Having engaged with the Traveller community at numerous events, visits and launches in recent years, I am acutely aware of the need for continued support for the community. On 9 October, I had the honour of being asked to launch Pavee Point's world mental health day exhibition, Unpacking Traveller Mental Health, which highlighted the specific experiences of the Traveller community. From these meetings with Traveller community organisations and representatives advocating on their behalf, it has become increasingly clear that suicide and mental health are issues of growing concern within the Traveller community. I noted with sadness the recent contribution from Bernard Joyce of the Irish Traveller Movement to the committee.

It is accepted that suicide rates are higher among the Traveller community when compared with those in the general population. To try to address this, the Traveller community was included as one of 23 priority groups at risk of increased risk of suicide under Connecting for Life, Ireland's national strategy to reduce suicide. Connecting for Life is a national and local strategy, with 17 local plans launched throughout the country. Progress under the national strategy is overseen by an implementation and steering group comprising cross-departmental and agency representatives. Each local plan involves local teams, including a resource officer for suicide prevention, local HSE staff, members of the Garda, county and city councillors, local community groups and others as relevant. Furthermore, A Vision for Change, Ireland's overarching mental health policy document acknowledges the importance of specific service developments for vulnerable groups, including the Traveller community.

The 2010 all-Ireland Traveller health study commissioned by the Department of Health continues to provide the benchmark for measuring progress on Traveller health. It found that approximately 60% of Traveller men and women said their mental health was not good enough for one or more days out of the past 30 compared to approximately 20% in the general population. The health inequalities experienced by the Traveller community are rooted in the social determinants of health that encompass accommodation, education and employment.

Despite the reported higher levels of ill mental health, take up of mental health support services in the Traveller community remains lower than the general population. The fundamental challenge of members of the community dying younger, having more illnesses and being at greater risk of substance misuse and mental health issues remains. Addressing this challenge is a priority for the Government.

The national Traveller and Roma inclusion strategy was launched in 2017 and contains 34 actions assigned directly to the HSE or the Department of Health. The strategy contains a set of specific actions aimed at improving the lives of the Traveller and Roma communities in Ireland. A key action of the strategy is to develop and implement a detailed action plan to address the health needs of the Traveller community. The lead role in developing this action plan rests with the HSE. A draft plan has been circulated and work is ongoing to finalise the plan. Responsibility for this action plan lies with the Minister of State, Deputy Catherine Byrne. The Minister of State and the Department are fully committed to ensuring the implementation of the plan.

More generally, since 2012 the budget allocation for HSE mental health services has increased from €711 million to almost €1 billion, which is an increase of approximately 27%. The Department of Health and the HSE have been developing several e-mental health initiatives targeted at increasing access to services for difficult-to-reach groups, including the Traveller community. These initiatives include telepsychiatry and telecounselling pilots, a new accessible website, yourmentalhealth.ie, the development of a crisis text line and a mental health signposting service in the national ambulance service.

The Department of Health, through the HSE, provides funding in the region of €10 million a year for programmes specifically targeted at improving health outcomes for the Traveller community, including primary healthcare projects, counselling, dedicated public health nurses, mental health promotion and culturally sensitive suicide prevention services. A further €500,000 is provided through the Dormant Accounts Fund for initiatives aimed at improving Traveller mental health, such as providing mental health community development workers and mental health advocacy workers for Traveller organisations.

The HSE National Office for Suicide Prevention funds Exchange House Ireland to address the mental health promotion and suicide prevention needs of the Traveller community in a culturally sensitive manner.

The Government recognises the need for a sustained effort in addressing mental health inequalities between the Traveller community and the general population.

I thank the Minister of State and call on Senator Freeman to make her opening statement.

I welcome the formation of the committee and the focus it will put on mental health in the Traveller community. As most of what is in my submission repeats what has been said, I will edit it as a I move along to focus on what I want to speak about.

I will jump straight into it with the crisis within general mental health services and the unacceptable inadequacies and underfunding in many key areas. Whatever I say, it is not directed under any circumstance at the Minister of State, Deputy Jim Daly. We have had serious problems in mental health services for decades, whereas the man has only been in position for two years and is trying his best. Everything I say is directed at the Department of Health because no one is listening in it.

I was Chairman of the Joint Committee on the Future of Mental Health Care which laid out in its final report in 2018 that there was much about which to be concerned in the availability and implementation of mental health services. This does not just relate to Travellers but to all of Ireland. That warning was also articulated in the Mental Health Commission's 2017 annual report. Such a note of alarm from the State's statutory body for the quality assessment of mental health services should be a sobering check for all legislators about the reality of service provision.

As a vulnerable group in society, a lack of adequate service provision is particularly detrimental for the Traveller community. As we have all highlighted, members of the Traveller community are less likely than average to reach out for help with their mental health. Forgive me for ad libbing, but I heard a suggestion last week of integrating services for the Traveller and settled communities. That will not work. We need to train people in the Traveller community in how to prevent suicide, offer therapy and look after their own. We have gained a reputation for being inaccessible, not compassionate; therefore, this is the only way we can start taking that small first step.

The committee will rightly be concerned with addressing the stigma and other barriers that create this disconnect, but all efforts will be for nothing if the services are not available when someone looks for them. There was the "Let Someone Know" advert, but once we let someone know, what then? There are no services to follow up. Let us consider, for example, the lack of consultant child psychiatrists in child and adolescent mental health services, CAMHS, in Wexford in the past year. A lady is present who has spoken about losing eight people in her family to suicide. People have been urged to reach out and look for help, but they have not been rewarded by the provision of support or even access to the inadequately staffed support services. This apathy is not just for the Traveller community. It is for all children.

The Joint Committee on the Future of Mental Health Care devised good solutions and suggestions on how to help the Traveller community. We acknowledged that there was a crisis in the Traveller community and knew the statistics, but let me be brutal. I am afraid that the report of the Joint Committee on Key Issues affecting the Traveller Community will be added to the 12,000 other reports that are gathering dust in this organisation. Someone needs to do something different. We will have a new Government in a few months' time. We do not know who the Taoiseach will be, but I appeal to that person to nominate someone from the Traveller community to the Seanad in order that we can have someone on the inside who will devote his or her term to tackling the problems of the Traveller community.

I am sorry for always being so cynical.

This committee may end up like the Joint Committee on Future of Mental Health Care in terms of the promise that it would be allowed to continue its work and it not having done diddly squat for a year now. The Taoiseach promised that he would allow that committee to continue. Where is it at? We have to stop kicking the can down the road because every time we kick it an inch someone else has died. I call on the Government to not only prioritise implementation of some of the suggestions that we have made over the years in respect of the Traveller community but to make mental health a priority. If we do not have our mental health, we have nothing.

I apologise for going off script, but I am pretty passionate about this issue. I am concerned that the eyes of Government glaze when it comes to mental health, children and the Traveller community.

I thank Senator Freeman for her contribution.

I apologise but I have to leave at this point.

I note the Senator's passion. We also need to note the recommendations of the Joint Committee on Future of Mental Health Care report that relate specifically to Travellers in our deliberations.

Following on from Senator Freeman's contribution I have concerns in regard to the work of the Joint Committee on Key Issues affecting the Traveller community. The purpose of this committee is to examine Traveller community life and, in particular, mental health within that community. In this regard, we are asking the Traveller community to come forward and tell us their experiences and, thus, this committee is taking on the responsibility for the future mental health of the Traveller Community. I hope it will not meet the same end as the Joint Committee on the Future of Mental Health Care, which, as mentioned by Senator Freeman, has not met for the last year.

Last year, €55 million was allocated to the mental health sector. A number of the mental health organisations have made the point that €25 million of that allocation has not yet been spent. Is this correct? The Minister of State might respond "yes" or "no". If so, why has it not been spent? A number of the Traveller groups contacted members of the committee and asked us to specifically raise the following questions with the Minister of State, Deputy Jim Daly. Will the Department of Health commit to supporting the implementation of the national Traveller health action plan, including ring-fenced funding and the establishment of an institutional mechanism with the HSE and the Department of Health to drive its delivery and implementation? Why has Traveller health not received any development funding since 2008, as opposed to once-off funding, given health inequalities and the findings of the all-Ireland Traveller study in 2010? Why has the Department of Health not provided targeted resources to address the Traveller mental health crisis given disproportionate levels of suicide and poor mental health? Will the Department of Health commit to providing resources to Traveller mental health from the additional €39 million allocated in budget 2020? Why has the Department of Health not implemented the recommendations of the Joint Oireachtas Committee on Future of Mental Health Care?

As discussed over the course of our meetings to date, the Traveller community feels that across the board in all Departments Travellers are not regarded in any way; they are treated as second and third class citizens. The view was expressed that future reforms across Departments should be proofed from the point of view of the Traveller community. It is important Traveller community issues are put on the agenda such that they are not left behind, as they feel they have been up to now.

Deputy Joan Collins has raised some very specific questions to which I now invite the Minister of State to respond.

Many questions were raised. Deputy Collins might remind me if I miss any one of them. The Deputy asked for a "yes" or "no" response on whether €25 million of the €55 million allocation for last year has not been spent. The answer is "no". There is €12 million yet to be spent and there is two plus months of this year remaining to spend it.

I am meeting representatives from the Department and the HSE tomorrow, as I do every couple of months, to review our spending targets and commitments on that front. Another question concerned new development money for Traveller mental health initiatives. I will ask the representatives from the HSE to address that more specifically, but I will state that new development funding is intended to roll out new models of care into communities. Examples would include eating disorders and any model of care for mental health and intellectual disability, MHID. We also have many different programmes for adults and children in communities, and Travellers can access these services and specialist teams.

We view Traveller mental health as something that requires a whole-of-government response. Mental health is a symptom and it has an impact on Travellers and the entirety of the Government has to take responsibility. We could just narrow this issue down, look at it through the prism of mental health and, if it were decided, set up dedicated specialist teams for Travellers' mental health. There are, however, many other minority groups and we cannot establish dedicated teams for each of those. We prefer to see groups established in the community and issues with access being addressed in that way. Those services must be culturally sensitive and there must be culturally-appropriate communications in order that people know how to reach out to and access those services. We prefer that model as opposed to establishing specific services.

Specialist programmes have been set up to address Traveller health. Exchange House Ireland receives about €1 million each year. I understand that programme has helped about 8,000 Travellers. There is also a €10 million programme for promoting Traveller mental health and wellness, in addition to the €500,000 I mentioned already from the Dormant Accounts Fund. Overall, the budget for mental health is more than €1 billion. Some 1,027 different services are available in communities. When I came into this job, I asked how many such services were available and nobody had the answer. I also asked how people knew about the services that existed. That is why the phone line now established in the national ambulance service went live last week. More than 1,000 services in the community are now available and accessible through that one phone number and I want to create awareness of that initiative.

This discussion has to be helpful and focused on improving access to the services available, as opposed to creating individualised services for minority groups. The most important thing is to ensure people can access those services and we must support them in doing so. I already outlined the targeted resources for Travellers. Turning to new development funding for Travellers from 2020, again we are open to suggestions. No one in this room has a monopoly on the wisdom regarding the right thing to do. I certainly do not, so I am very happy to hear any suggestions from this committee on ideas for new developments to support Traveller mental health specifically. I state that because it is a crisis. There is no doubt about that at all and we want to support and assist in addressing this issue in every way possible.

Is Deputy Joan Collins happy that her questions have been answered?

The Minister of State referred to €12 million outstanding or having to be spent in the coming two months. He also mentioned that he is meeting representatives of the HSE tomorrow. Will he issue a statement outlining where that money is going to go in the next two months? It will then be clear and transparent as to where the money is going and how much is being ring-fenced for children, the Travelling community and mental health.

The Minister of State also mentioned the funding for the Exchange House Ireland and the developments under way to try to provide access to communities via the emergency phone number. All the information we have received in the past two to three weeks, however, is that it is not working. The Minister of State is correct when he states no one has a monopoly on knowing what is the right thing to do. We have to drill down into discovering how we can provide the community with access and ensure the people involved are equipped to deal with those issues. I am hopeful that our recommendations will raise some aspects that will assist the Travelling community, because those are the voices that have to be heard.

I thank the Deputy. Does Senator Warfield have any questions?

I want to address an issue already raised by Deputy Joan Collins concerning the Traveller health action plan.

I understand that a draft plan has been circulated to the community and non-governmental organisations, NGOs, but some people are dissatisfied with the draft plan. Has the Minister of State seen the report? Is he satisfied with the recommendations for mental health? When will the report be launched?

Can the Senator clarify the name of the report to which he refers?

The Traveller health action plan.

I would say that is the report I referred to and it is under the jurisdiction of the Minister of State in my Department, Deputy Catherine Byrne. She is the lead Minister on that so I have not seen the plan. That is a whole-of-government report.

Senator Freeman has mentioned the all-party Oireachtas joint committee report and its recommendations concerning Travellers. Does the Government intend to implement the recommendations?

Specifically on the recommendations by the Oireachtas Joint Committee on the Future of Mental Health Care and refreshing A Vision for Change, which is the overarching policy that drives the Government's mental health policy, as the Senator will be aware we have been refreshing the policy document for some time. I hope to bring the final version to Government in the next two or three weeks. During the process the recommendations were taken into account. In particular, the issues surrounding Traveller mental health are referred to in the refreshed A Vision for Change, which will be published in the coming weeks.

When will the all-of-government health action plan be launched?

I do not have the information to hand but I can find out for the Senator and will revert to him.

I hope that the plan will be launched before the end of term. Did the Minister of State seek increases in the budget in order to address the issue that we are speaking about today? Did he have such conversations?

Yes, I did and this year €39 million has been added to the mental health budget, which brings the total to €1.026 billion. Traveller health is part of that. However, when it comes to moneys, there are many competing demands but they are all factored in.

The Minister of State seems to accept that there is a crisis among Travellers around mental health and he does not dispute the figures, prevalence and scale, which is important. The all-Ireland Traveller health study 2010 is out of date although we still rely on it. The Irish Traveller Movement has estimated that there have been 30 deaths to the end of August. On what data does the Minister of State base his Department's response to the mental health crisis? I have more questions.

I do not dispute that there is a crisis. This committee was established in response to a dreadfully serious issue, which is how politics is supposed to work. I do not in any way, shape or form intend to diminish the seriousness and challenges of this issue. I want to be as proactive as I can with this committee, and anybody else, who will try to reach out and achieve a solution.

As for what data my Department relies on, I agree with the Chairman that 2010 is a long time ago, in terms of our reliance on the findings of the Traveller health study 2010. A lot of my own information has been gleaned from my engagement with representative groups like Pavee Point. I have also met individual Travellers who have told me the issues that affect them in stark terms. I do not want to mention names but people will know who I am talking about. Such engagement has motivated me and led me to use certain terminology a while ago. There are things that we can do, things that we should do and obviously we can always do more. I have spoken to Pavee Point about exploring ways to make the signposted phoneline that exists more culturally sensitive and aware of the issues that affect Travellers.

There might be some way we could feed into that telephone line vis-à-vis training in the National Ambulance Service to ensure that people have assistance and guidance on recognising issues that are specific to Travellers. Under the safeTALK training that has been rolled out, and John Meehan can speak further on this, MORE than 2,000 people have been trained in the last 12 months. Every member of An Garda Síochána in the Garda Training College has been trained in that. Perhaps we could examine a dedicated programme to be rolled out among Travellers. It is training specifically on recognising suicidal ideation and equipping people with the correct and appropriate language to use.

Certainly, there are things we can do and I look forward to this committee informing some of that for me, the staff in the Department and the HSE.

How much of the extra €39 billion might Travellers expect to see devoted to services, both mainstream and specialised? I heard what you said about mainstream services but there is a case for having both mainstream and specialised. We need to think in binary terms about services, particularly when issues have been raised time and again about access to culturally appropriate services. First, are you open to both specialised and mainstream services? Second, how much of that €39 billion is likely to come the way of Traveller mental health, given that you accept there is a crisis?

On the €39 million, the national service plan will decide its allocation. That is something on which I and my officials will have to engage with the HSE-----

I am sorry, it is €39 million, not €39 billion.

We wish. The €39 million is something we will have to address collectively. I cannot prejudge that here and give a commitment to anything specific. However, I repeat that I am open to any suggestions and ideas that will come from this committee in time for that service plan. The discussions on the plan will take place in the next number of weeks so this meeting today is very timely to focus our minds, attention and, hopefully, resources on that as well.

To be clear, I repeat what I said earlier about the specialist services. We could try to recreate CAMHS teams and similar highly specialist services especially for Travellers, but I do not believe that would be the way forward at high specialist level. I want to focus on access. That is what I have done from the first day I was appointed Minister of State with responsibility for mental health. We have looked at the online space, which is about providing mental health assistance 24 hours a day, seven days a week to people where and when they need it. That is the future, whereby people can access help through their telephones, iPads or in local community primary care settings where they can call into their GP and have the provision of these services 24-7. We are rolling out pilots of telepsychiatry and telepsychology. Again, it is improving the access to these services and ensuring they are available when and where they are needed. All of that will benefit Travellers as well as anybody else. It is about focusing on access and making services more accessible to people when they are needed.

One of the issues that arose in the last couple of meetings is the implementation of the ethnic identifier which was recommended in the National Intercultural Health Strategy 2007-2012. It still has not happened. Also, there was the issue of the Central Statistics Office, CSO, basing it on accommodation, but only 6% of Travellers live on halting sites. That has to change as well from the point of view of an ethnic identifier. What is the Minister of State's position on that? Is that part of an implementation plan?

I am not familiar with it. John Meehan said he will address that when he is due to speak. I refer to the broader point I made earlier regarding mental health being a symptom. There are serious challenges for society with regard to stigma, people's attitudes and approaches, how they view employment and education, access to employment and education and treating Travellers the same as anybody else on a level playing field. These are real and significant challenges. Regrettably, the result of these things not happening is an increase in mental health issues among Travellers. We must look at the source as well as the symptom. That is a broader point.

I agree with the Minister of the State, but the playing field is not level from the point of view of the issues facing the Traveller community in education, health and so on.

As well as employment. It is about attitude and stigma as well as challenging society as a whole.

The committee will produce its interim report shortly. It would be timely, as the Minister of State said, to feed that into the discussions on the allocations of the €39 million. Clearly there is a crisis, and this is borne out in all the evidence the committee has heard, and we have only scratched the surface in terms of the numbers of people we have been able to hear from directly and from the many submissions we have received. We would welcome a commitment by the Minister of State that the interim findings of the committee will feed directly into that process for 2020. People are dying and we cannot wait. There is an urgency to take action in this area.

Traveller organisations say the establishment of a national Traveller mental health steering group would be important and would like to see the development of a national Traveller mental health strategy within the strategy. It is not a case of either-or but to do both within the allocation of the resources we have been talking about. Will the Minister of State give a commitment regarding the recommendations of the report of this committee feeding directly into what will happen in 2020, and not pushing them out into the future, given the immediacy of the crisis upon us?

Yes, I can. The national service plan will address how we spend €1 billion plus €26 million. It is not just the additional €39 million funding this year. There has been additional funding in the past five to six years of more than €300 million. There is significant funding to be allocated across the board and it is a case of how we do it and what we do, and doing it better. I have always tried to promote that. If we always do what we always did, we will always get what we always got. It is about finding new ways of allocating these moneys and looking at how we do what we do.

I will give the Chairman an absolute commitment that in the national service plan, I will be more than happy to consider the recommendations of the interim report from this committee vis-à-vis the allocation of €1 billion plus towards the support of mental health.

That would be welcome. A comment was made by Mr. Thomas McCann, who is in the Gallery, which Ms Minnie Connors echoed, about the indifference of the State to the plight of people in this level of crisis. Does the Minister of State wish to comment on that indifference, which would seem to be a theme that runs through many of the submissions we have received?

Will the Chairman clarify what she means by the indifference of the State?

The indifference of the State to the crisis in mental health among the Traveller community.

I only can speak for myself. It is not for me to cast my eye over the history of the State's treatment of people. As I have acknowledged, this is a crisis. I am happy to acknowledge that again, but that does not give me or anybody in this room any comfort whatsoever. The State has responded to suicide overall with the establishment of the National Office of Suicide Prevention and Mr. John Meehan, head of the office, will talk in more detail about the issues. The funding of his office has grown exponentially in the past number of years. I am not saying this defensively; it is a matter of fact.

As I said at the outset, I do not have a monopoly of wisdom on how to deal with this issue and a whole-of-society approach is needed. That is the reason it has been tasked for a whole-of-Government report led by the Department of Justice and Equality, which is the lead agent in driving issues affecting Travellers. Mental health is more of a symptom of the malaise of the treatment of Travellers than itself being an issue. There are developments all of the time. For example, the online space and crisis text line is being developed as we speak and we hope it will be available in a number of weeks. Crisis Text Line has had phenomenal success throughout the world, giving people access to support and help at a time of dire need and preventing suicide. We are developing a number of initiatives and will continue to develop the service. I recognise that we could be more culturally sensitive and aware in the development of the crisis text line and have a look at how we could tailor it more to the needs of Travellers before the end of this year.

I thank the Minister of State. I welcome very much that he has acknowledged the crisis and is open to looking at the allocation of resources to respond to that crisis. That is noted by the committee. We will act swiftly in order that we can input into the 2020 service plan process.

I thank the Minister of State for coming. I appreciate his candour and willingness to listen. I am looking forward to working more with him on this very serious matter.

I thank the Chairman very much.

Ms Kate Mitchell

I thank the Chairman and members for inviting representatives of Mental Health Reform to appear before the committee. We welcome its establishment and the attention it is giving to the important issue of mental health in the Traveller community. Mental Health Reform is the leading national coalition on mental health, with over 75 member organisations, including groups such as the Traveller Counselling Service, Exchange House and Pavee Point. We work together to drive progressive reform of mental health services and supports. In its manifesto, published in 2012, Guiding A Vision for Change, Mental Health Reform identified that community mental health services had a duty to meet the mental health needs of all members of the community, including those in the Traveller community. Mental Health Reform also highlighted that the particular challenges of some minority and marginalised groups such as members of the Traveller community led to social exclusion and increased mental health difficulties. Mental Health Reform has since published a position paper on ethnic minorities and mental health which documents the challenges such individuals, including from the Traveller community, experience in accessing appropriate mental health services and supports. Such challenges include reports of lack of quality in care, communication barriers, over-reliance on medication, negative experiences with staff, the cost of accessing supports and experiences of inequality and discrimination. Perhaps most important of all is the reported lack of understanding among professionals of individuals' social and cultural context and a sense that the mental health system has been designed to reflect the majority culture. Such a lack of understanding and appreciation of Traveller culture makes it impossible to provide mental healthcare in a way that respects that culture and fulfils Travellers' human rights to culturally sensitive care. To clarify, when we speak about cultural competence, we are referring to the attitudes, behaviours, knowledge and skills mental health services and staff need to have in order to deliver culturally responsive mental health services, while recognising that such competencies must incorporate the addressing of power imbalances and institutional discrimination.

In 2016 Mental Health Reform published, in partnership with the Mental Health Commission, guidelines for mental health services and staff on working with people from ethnic minority communities and delivering culturally sensitive care. The key recommendations outlined in the report include that staff and services respect the diverse beliefs and values of the people using the services; the provision of communication and language supports; the facilitation of family and advocate involvement in providing support and training for mental health staff, to include reflection on inherent cultural biases and the evaluation and review of the delivery of culturally sensitive services. It should include the establishment of an ethnic identifier to collect data for service utilisation, equity of access and quality of service for persons from ethnic minority groups.

I would like to highlight two key points in my opening statement, the first of which is that the experiences of social exclusion and discrimination felt by the Traveller community increase the risk of mental health difficulties. These issues must be addressed effectively if we are to improve the mental health outcomes of this community. The second point is that the lack of culturally sensitive mental health services results in the particular mental health needs of members of the Traveller community not being met. This must be addressed as a matter of priority.

With regard to social exclusion and discrimination, the all-Ireland Traveller health study, published in 2010, identified discrimination as being a major problem for all Travellers. There were significant numbers of accounts of it directly influencing mental health, leading to feelings of depression and anxiety and suicide. A report published in 2017 by the Community Foundation for Ireland identified that 77% of Travellers had experienced discrimination in the previous year. Some 43% indicated that they had encountered discrimination while accessing employment. High rates of unemployment and poverty, over-representation in prisons and experiences of unsuitable accommodation among members of the Traveller community continue to be reported. There can be no doubt but that they are compounded by cuts to Traveller services in recent years.

As outlined in Travelling with Austerity, significant cuts to Traveller infrastructure were highlighted, including cuts of more than 80% to Traveller education and Traveller accommodation and more than 70% of cuts to equality programmes. The community and voluntary services that provide essential mental health supports to Travellers at local and national levels must be acknowledged. These services, however, are often under-resourced and operate on insecure funding streams and budgets. Under human rights law, the Government is obliged to “ensure that health services are culturally appropriate and that health care staff are trained to recognise and respond to the specific needs of vulnerable or marginalised groups”. At national level, the Government’s current mental health policy, A Vision for Change, recognises that mental health services should be inclusive of all people in Irish society and should be delivered in a culturally appropriate way. This sentiment is reflected in Mental Health Commission’s quality framework. The requirement to meet the particular needs of the Traveller community has also been committed to in Connecting for Life, the national intercultural health strategy, and more recently the national Traveller and Roma inclusion strategy. While these commitments are welcome, to date there has been a severe lack of implementation and policy is far removed from what is happening in practice.

It is anticipated that the revised mental health policy, due to be published later this year, will have a greater focus on developing mental health services for particular groups of people, including those from the Traveller community. Mental Health Reform continues to hear reports that the Traveller community feel their mental health needs are being ignored, notwithstanding serious concerns about high rates of suicide and mental health difficulties within the community. Many Travellers feel there is a lack of engagement with the Traveller community and where their concerns are voiced they often fall on deaf ears. The Oireachtas Joint Committee on Future of Mental Health Care acknowledged that clearly there is a mental health crisis in the Traveller community, and that mental health services are failing Traveller people the most. In its October 2018 final report the committee recommended "that the Department of Health carry out a study to identify the causative factors [of mental health difficulties] to include a priority focus on the Traveller Community, and how they can be addressed", and that "more resources and funding should be targeted at the areas of highest need with particular attention to the Traveller Community and towards addressing suicide." There is no doubt of the need to implement in full the recommendations of the Oireachtas committee, including those pertaining to the Traveller community. There is a fundamental need to adequately address the mental health needs of the Traveller community through national policy with the voice of Travellers at the heart of the process, and to effectively resource and implement such a policy. Traveller-specific infrastructure, including local community groups and primary healthcare projects, must receive adequate investment through sustainable funding. Mental health services and supports must be developed to deliver culturally sensitive services and to ensure equity of access and quality of care among the Traveller community.

I remind Ms Mitchell of her time. I am conscious that we will have time to hear all the other speakers also. Perhaps the witness could sum up.

Ms Kate Mitchell

Yes. If mental health outcomes are to improve among the Traveller community a cross-departmental approach is essential to address the ongoing inequity and inequality experienced by Travellers around early school leaving, low educational attainment, unemployment, poverty, and inappropriate accommodation, among a myriad of other issues.

I thank Ms Mitchell. I call on Dr. Keogh to make his opening statement. I remind witnesses that five minutes is the time allowed and I ask that they keep to that. It means that committee members will get to ask questions of the witnesses.

Dr. Brian Keogh

I thank the Chairman. I am an assistant professor in mental health nursing at the school of nursing and midwifery in Trinity College Dublin. In my statement I will draw from work that was completed in Carlow and Kilkenny during 2018 when we evaluated the role of the mental health liaison nurse, a post introduced to support Travellers who were experiencing mental health difficulties.

Travellers are not a homogenous group and care must be taken not to apply stereotypes and make assumptions about their needs or abilities. An individualised approach is required and approaches that are sensitive, non-judgmental, unrushed and respectful will assist towards meaningful engagement. The importance of relationships, the development of trust, privacy and confidentiality should not be understated. Recovery-orientated approaches should underpin all services and interactions with Travellers. Meaningful involvement of Travellers in the design and delivery of services is essential.

Cultural competence training should be mandatory for mental health service providers who are in close contact with Travellers on a regular basis.

Any strategy to support the mental health of Travellers needs to consider the social determinants of health and how they can impact negatively on the mental health of Travellers. For those who are vulnerable to developing mental health difficulties, strategies need to assist Travellers to recognise mental distress and develop self-help strategies, including help seeking strategies, to manage their distress and prevent it from worsening. For those in receipt of treatment from mental health services, strategies to assist Travellers to remain in contact with the services and adhere to treatment plans, where appropriate, need to be developed. Traveller health projects already in existence are in a prime position to promote positive mental health, but they need to be supported to do so. For Travellers who are in receipt of care from mental health services, service providers need to understand why Travellers might be vulnerable to disengaging from the services. Traditional ways of informing people about appointments or medications, etc. may not be useful for Travellers for a variety of reasons. Interventions need to be tailored to meet individual needs and take into consideration issues such as literacy levels and others that might impact on their engagement with services. There are also opportunities for mental health services to work closely with Traveller health projects in engaging with the Traveller community and addressing some of the barriers between Travellers and mental health services such as stigma.

In 2018 my colleagues and I evaluated the role of a Traveller mental health liaison nurse in Carlow and Kilkenny. The liaison nurse works within the primary care system and supports Traveller community health projects in a number of ways such as by educating Travellers, liaising with other professionals and community organisations and facilitating access to primary care services, or re-engagement with mental health services, when necessary. She also provides a follow-up and reminder service. This model of mental health service provision supports existing services, including the traditional mental health services, and was evaluated positively by key stakeholders, including Travellers. Some of this success can be attributed to the relationship the liaison nurse has built up with the Traveller community and her use of wellness and recovery oriented strategies to support individual Travellers who are experiencing distress. In addition, her comprehensive knowledge of community resources is instrumental in helping Travellers to access the assistance they require. Furthermore, she has forged relationships and worked closely with other agencies such as social workers and substance misuse services in facilitating access and helping professionals to understand the specific needs of Travellers.

Stigma and social exclusion are major problems for members of the Traveller community. In addition, mental health difficulties are stigmatised, leading to a lack of openness about mental distress and a reluctance to engage with the services, where necessary. Educational supports and good relationships with healthcare providers will go some way towards breaking down some of the barriers, while Traveller community health projects are in a good position to do this in partnership with mainstream organisations.

Suicide is a significant issue among members of the Traveller community. Travellers have been identified as a priority group within the national suicide prevention strategy. The introduction of the liaison nurse in Carlow and Kilkenny and the Traveller community health projects respond to some of the strategic goals of the national suicide prevention strategy such as supporting the community's capacity to prevent and respond to suicidal behaviour. A gendered response is necessary in the Traveller community. Traveller men are particularly hard to access and reluctant to engage with mental health services. Possibly the most effective strategy to reduce the incidence of suicide is tackling social exclusion, in particular, unemployment and the lack of a meaningful occupation that Traveller men often experience.

LGBTQ+ Travellers face the potential for discrimination within their community which tends to have strong conservative and religious values. There are many resources for LGBTQ+ people throughout the country and raising awareness of these supports as an avenue for open and confidential discussions about sexuality may encourage access to them byTravellers, especially young people. Traveller health projects may facilitate a sharing of information on the services and supports available.

I thank Dr. Keogh for his strong endorsement of Traveller health projects and the role of the liaison nurse. We may pick up on that point when we speak to representatives of the HSE. I call Dr. Tierney to make her opening statement and thank Dr. Keogh for keeping to the time limit.

Dr. Aileen Tierney

I thank the joint committee for inviting me to speak to it. I welcome its establishment at what is a time of crisis for Travellers.

I come from the Clanwilliam Institute, which is a registered charity founded in 1982. We provide systemic family therapy services and train mental health professionals. Clanwilliam has been involved for 31 years in that provision. Our approach to therapy is embedded in reflexive practice, which creates problem-solving competencies for clients and fits with a community-centred approach, to build resilience. We provide a counselling service that is responsive and tailored to each client group’s specific needs. A significant part of our education and training is about taking into account the lived experience of our clients and the impact of their culture and how they perceive their world and their place in it. All our therapists are trained in cultural competency.

We are in partnership with the Traveller Counselling Service, which was launched in 2008 and has developed into a community-based counselling service led by Thomas McCann. This service works from a culturally inclusive framework. Clanwilliam and the Traveller Counselling Project have been in partnership in the provision of services to children and families and this collaboration is underpinned by the mutual shared interest of both our agencies in the provision of family therapy to marginalised groups and in particular to members of the Traveller community.

We need to begin to consider the position that any organisation such as Clanwilliam can hold in supporting positive mental health for Travellers. The voices of Travellers must be included in the planning and delivery of all mental health services. Drawing on the disability slogan, "nothing about us without us", Travellers must be included at every level of service delivery.

The Clanwilliam Institute's role is as an ally and a partner in consultation with the Traveller-led counselling service. If people do not see that people of their race, ethnicity, culture, class, sexual orientation and ability are widely represented in newspapers, on television or in all the structures in society, it is very difficult for them to hold a positive view of their own position as fully accepted members of society. As I began to meet the children, families and women from the Traveller community, I thought of myself as a culturally sensitive therapist. I somehow believed I had some knowledge of marginalisation and discrimination and its impact on people's lives. Having frequently experienced marginalisation as the parent of someone who lives with a disability label, I thought I might understand them a little. I falsely assumed, however, that I knew something about the possible experiences of others or, if I did not know, that I would be curious and sensitive enough to inquire about what I needed to understand of cultural beliefs and practices that might affect therapy conversations. Culture, however, does not reveal itself, it cannot be inquired about and it is not available to questioning. It is embedded in ways that are subtle and sometimes hidden. At times power occludes the possibility of our seeing our own capacity to oppress, not power as an expert stance or any therapeutic arrogance, but the power by virtue of being. The internalised history of being silent often meant that my clients from the Traveller community were not even able to let me know the times when I was misguided in my conversations. I had to rely on a heightened sensitivity to voice tone, posture and demeanour, always conscious that people who have experienced marginalisation can internalise expectations of what it means to be from that community, that is, an expectation not to be listened to or to pass expertise to members of the dominant community.

The most interesting feature of my responses was that I could easily oscillate between shame, sadness, outrage and a feeling of hopelessness and powerlessness in my work with the Traveller community. I felt shame at being settled and what my people and I do and have done to others and for not really understanding the lived experiences of others. A deep sense of sadness often pervaded my reflections on working with Traveller populations, which was related to the complexity of the difficulties at every level, from access to housing, health services, education to being a witness to the repetitive cycles of exclusion and the challenges in the next generation. There was sadness at the displacement of young men struggling to find their identity and the high suicide rates and I felt rage at discrimination. My sense of powerlessness came from my incapacity to support change, including the attitudinal change of other professionals in making judgments that did not always take culture into account. Sometimes I felt my own voice when working with Travellers was silenced within my profession. At times it seemed the issues were too complex to create sustainable change and the desire to be political as a therapist, to impact societal and structural changes and to begin to advocate at a political level, became more imperative.

Among the themes that emerged from my therapeutic work and that seem significant in forming any recommendations I might make was the idea that Travellers are often caught between two worlds, settled and Traveller, when trying to navigate systems and legislation that had not been set up with cultural sensitivity.

Childcare systems are often not created with cultural sensitivity. For example, there is a lack of relative foster care placements for Traveller children in our care systems. I refer also to addiction and a lack of services that are culturally inclusive, as well as GPs prescribing and over-medicating the Traveller population, particularly Traveller women. The risk of suicide is higher in marginalised populations and particularly among young men. We have been noticing Traveller mothers preparing their children to manage discrimination and note the need for the State to police the role of social workers and psychologists to receive and undertake cultural sensitivity training.

As Dr. Tierney is at six minutes, can she come to her recommendations?

Dr. Aileen Tierney

I will move to some of the recommendations. We recommend a focus on young men in particular, who often feel displaced, are early school leavers and cannot access employment and education; a focus on supporting young women in families who are often isolated rearing children; and a focus on building trust. Members of the Travelling community have often experienced discrimination, racism and marginalisation and trust is really essential in service delivery. It requires respectful communication, valuing views and opinions, and honest transparent information-sharing to create dialogue and collaboration between settled communities and Traveller groups. We recommend respecting the history of oppression and healing that history; developing the ability to consider Traveller representation in all levels of society, school boards, health services, Government committees and political representations; and providing services that are informed by values of anti-racism, ethics and inclusion with mandatory training in cultural competency for all mental health professionals. We recommend providing a continuum of mental health services, from local Traveller-led peer support groups and information services to Traveller-led counselling services to partnerships with specialist services such as ourselves, to deliver culturally sensitive mental health services. We recommend devising a national Travellers' mental health strategy that is Traveller led; and resources and a personal commitment of Government representatives to address the history of exclusion, marginalisation and oppression of Travellers. Finally, I refer to shame as a call to action, and shame for the history in Ireland in respect of the appalling treatment of Travellers.

I thank Dr. Tierney. We have her full submission. There was a lot in it. The call to action driven by a sense of shame is important and interesting. I now call on Mr. Meehan to make his opening statement.

Mr. John Meehan

I am the assistant national director in the HSE responsible for mental health strategy and planning. I also head the National Office for Suicide Prevention, which I will refer to as the NOSP. I am joined by my colleague, Dr. Siobhán Ní Bhriain, national clinical adviser and group lead for HSE mental health. On behalf of the HSE mental health services, I welcome the establishment of this committee and its focus on mental health within the Traveller community. In the context of our own health services, mental health describes a spectrum that extends from positive mental health through to severe and disabling mental illness. A strategic goal for mental health services is to promote the mental health of our entire population in collaboration with other services and agencies, including reducing loss of life by suicide. This requires a whole-population approach to mental health promotion. Over 90% of mental health needs can be successfully treated within a primary care setting with a need for less than 10% to be referred to specialist community-based mental health services. Of this number, approximately 1% are offered inpatient care and nine out of every ten of these admissions are voluntary. I offer a reminder today that our mental health services, whether provided by community-based mental health teams or within acute inpatient services, day hospitals, outpatient clinics or forensic services, are for our entire population and that includes the Traveller community.

On suicide and mental health among Travellers, it is widely accepted that there are many factors that can impact on the mental health of the Traveller community including, but not limited to, perceived stigma associated with being a Traveller and discrimination against Travellers among the general population; lower educational levels; socioeconomic conditions; inadequate accommodation; addiction; domestic violence; and inclusivity among the Traveller community as regards LGBTI+ and gender equality. Nevertheless, it remains difficult to ascertain the levels of suicide among the Traveller community. Unfortunately, the data provided by the Central Statistics Office do not capture a wide range of information, including ethnicities. This gap is just one of the barriers to improving real-time visibility of suicide incidence among many different cohorts in society. However, we can still look to qualitative studies.

The 2010 all-Ireland Traveller health study, although somewhat dated, concluded that the rate of suicide among male Travellers was 6.6 times higher than the general population. The female suicide rate was less pronounced.

In a strategic context, I would like to highlight four key drivers that inform and assist us in the HSE in improving the mental health of, and reducing suicide among, the Traveller community. First, members of the Traveller community are considered as a priority group in Connecting for Life, and feature across many objectives and actions in the strategy. They are strongly represented in 17 localised versions of Connecting for Life that are now in place across the country, many of which involve local Traveller groups and representatives on their implementation or oversight groups.

A Vision for Change reminds us that mental health services should be inclusive of all the people in Irish society and should be delivered in a culturally appropriate way. A refresh of A Vision for Change is due to be completed later this year and will propose an expansion of existing recommendations, as well as seeking to develop a framework for the implementation of cultural, diversity and gender competency that is required to respond to the needs of these particular groups. The national Traveller and Roma inclusion strategy also details HSE-specific actions which inform this work. Of particular note is the commitment to develop a national Traveller health action plan. In answer to Senator Warfield's question about the action plan, a senior manager in the HSE has been allocated to work with Travellers to complete it and it will be done by quarter 1 of 2020.

The consultation process to inform the development of the plan, led by the HSE national social inclusion office, commenced in 2018. Along with the HSE community strategy in planning mental health, the office has proposed an integrated approach to deliver key mental health and social inclusion actions under the national intercultural health strategy, which includes Connecting for Life, A Vision for Change and Healthy Ireland, alongside wider Government initiatives. The second National Intercultural Health Strategy 2018-2023 provides a comprehensive and integrated approach to addressing the many unique health and support needs experienced by the increasing numbers of HSE service users from diverse ethnic and cultural backgrounds who live in Ireland.

There have been key initiatives and developments across the HSE, nationally and locally. In 2017, the HSE committed to the recruitment of nine mental health co-ordinators for Travellers, eight of whom are currently in post. The focus of these roles is to work within the CHOs to support improved access, consistency and integration of mental health services to meet the mental health needs of Travellers. The HSE NOSP provides suicide prevention-specific funding to Exchange House, from which the committee heard last week and whose service has now established working groups in Dublin, Limerick, Sligo, Meath, Waterford, Kildare and the midlands. The NOSP has also funded the Offaly Traveller Movement and the local community healthcare organisation, CHO, to provide the local Travelling to Wellbeing mental health service. This has resulted in the production of a guide to developing a local co-ordinated multi-agency crisis response plan for the Traveller community to ensure more support for individuals and families when suicide incidences or crisis situations occur. The HSE national social inclusion office funds a wide range of Traveller mental health initiatives that are focused on both improving the mental health and reducing death by suicide of Travellers through training and education programmes but also through providing a community development approach to service access and delivery. Many of these initiatives are based in CHOs and a number are funded directly through dormant accounts.

Last week, the committee also heard from Ms Niamh Keating, from the West Limerick Primary Health Care Project for Travellers. Primary health care for Travellers projects, PHCTPs, establish local models for how Travellers could take part in developing health services. Travellers work as community health workers and this will allow primary health care to be developed based on the Traveller community’s own values and perceptions. This helps to achieve positive outcomes with long-term effects. It is just one example from an array of initiatives under way within Traveller health units across each CHO area in the HSE. These units provide support to a range of primary care projects and other initiatives for Travellers.

The Traveller health units, as discussed previously, work to enhance Traveller health status, improve the capacity of mainstream health services to respond to Traveller needs, and to respond to the social determinants that impact Traveller health. The latter issue has been mentioned by many of my colleagues.

There remain challenges across our health system in accessing Traveller populations, and in responding to their specific needs, but the HSE believes that targeted, evidenced local initiatives can make a difference. For example, projects to introduce regional Traveller mental health liaison nurses, mental health promotion programmes, Traveller cultural awareness training and programmes such as Healthy Minds, which was discussed in Cork and Kerry previously, all have promising outcomes. A wide range of local Traveller projects or action groups have nurtured constructive relationships and partnerships with HSE community health organisations in this regard.

I assure the committee and representatives here today that there remains a very firm commitment, at national and local levels, to improve the health service experiences and reduce mental health inequalities experienced by the Traveller community in Ireland. We hear, and share, the concerns about mental health and levels suicide among the community, and remain determined to work collaboratively with all partners and stakeholders, to achieve better outcomes together and to reduce suicide and self-harm among the Traveller community and the general population. That concludes my statement.

I thank Mr. Meehan for his presentation. Are there any questions from the committee members?

I thank everybody for their presentations here this afternoon on this very important work the committee is doing.

I was very interested in Dr. Tierney's reference to young men and education. Does she have any suggestions on the types of programmes that might be attractive to them? I have come across some young men myself who were interested in farriery, yet there is not anywhere for them to train in the South. I understand they would have to go to the North or the UK. Could we do something to address that? Is Dr. Tierney aware of any research on suitable areas of education for young men? There is no point in channelling them into areas they do not want to be in, regardless of their background.

I have a question for Dr. Keogh on nursing liaison, which the HSE has addressed to some extent. We had a discussion on the issue last week. It seems to be a very good model whereby people are trained to develop specific expertise in helping people within the Traveller community who are having difficulties. Could Dr. Keogh outline a little more about the way the nurse works in Carlow because it would be well worth doing it, if that is something that could be replicated across the country?

The HSE statement referred to the fact that there is a gap in the CSO's data in terms of information gathering. Has the CSO been approached in order to address that and, if so, what is the progress in that regard? That would be something important for us to identify in making our report. It would be helpful if the HSE witnesses could tell us if there has been any engagement in that regard.

Dr. Aileen Tierney

Young men are a particular group that I am very concerned about. They are quite isolated and so the risk of suicide is higher. For me, it relates to inequality in terms of education and employment, but some of it is historical. When parents have had poor experiences of education they are less likely to be positive about education.

Deputy Corcoran Kennedy is looking for specific projects. Young men I have met in the Traveller community often marry younger and want to move into employment earlier. The kinds of training programmes she is talking about that would be of particular interest to young men would have to have a remuneration component. The programmes would have to help them to move away from potential addiction trajectories, lack of employment or further discrimination, which impact on their self-esteem and their views of themselves.

I am sure it is possible to develop some schemes. Last week I heard someone speak about the law on horse ownership. If the legislation was more culturally sensitive some of the young men might be interested. In terms of specific projects, it might be useful to hear from young men on what they think might be helpful to them. I see them as a group that has great difficulty in accessing mental health services.

From the settled population 20 or 30 years ago, we saw that women access services first. We are still seeing that. To make services accessible for young Traveller men, there may need to be gender-based services and the possibility of gaining access to services in which male therapists and counsellors are available.

Dr. Brian Keogh

With regard to how the mental health liaison nurse works, when we did the evaluation she was in place for about two years. She had spent considerable time building up relationships with the community and the health and social care agencies in Carlow and Kilkenny. She worked with individuals, groups and the health and social care agencies. When she met people individually, she engaged in listening, support, reassurance, education and advice, and then pointed them in the right direction. She had a great knowledge of the services available in both of the counties. She was able to put people in touch with the relevant organisations and advocate for them in some cases. She could contact the Housing Agency or social work services on a Traveller's behalf to discuss the matter in question. She was also involved in crisis intervention. When Travellers were in crisis, she was able to speak to them and work out a plan to address certain issues. Much of her work was on signposting, to either community organisations or non-governmental organisations, or to primary care services through general practitioner services. For example, she might have told a Traveller that he or she needed to make an appointment with a general practitioner but an issue might have arisen in that he or she might not have been registered with a general practitioner. Part of her job in that case was to make sure that the individual could be registered. The approach was individualised, depending on the case. The nurse knew all the agencies and was able to support families. Where parents said their children were misusing substances, she was able to provide some sort of support and recommend services. She recommended such services to the family members in addition to the Traveller who came for the help in the first place.

It struck me on listening to the response that it would be great if Travellers who wish to become nurses themselves could have such a role. I am guessing there is a rather large gap to be covered there.

Mr. John Meehan

In response to Deputy Corcoran Kennedy, suicide can be determined only by a coroner. It cannot be determined by anybody else, such as a doctor in the HSE. Internationally there is a challenge related to identifying specific groups and cohorts of those who have died by suicide, particularly in Ireland considering we have a small community and sensitivities about identification and the associated stigma. This has, however, been addressed internationally with coroners to seek solutions. One cannot identify anybody's sexuality, for example. Connecting for Life has a focus on priority groups. It is very difficult to identify priority groups because the coroner will not determine these. This involves a big conversation that cannot be had in isolation. Internationally, there is a movement, in which Ireland is involved, to open up this discussion with the coroners to determine how we can target specific data in coroners' reports. Currently, the National Office for Suicide Prevention is working with coroners on reviewing previous cases to determine whether they could be learned from. Currently there is no plan to provide the identity. Thankfully, the conversation has happened, and the approach needs to be very sensitive.

May I ask a question I meant to ask earlier, if my colleagues do not mind? I was thinking about the men's shed model. It was stated that getting men to engage is a challenge. Has any work been done on determining whether a model such as the men's shed model could be useful in getting Traveller men to engage through some form of informal gathering? Many of them have many skills that they might be able to share, or they could share their stories or engage in conversation. To me, the men's shed model is a great one. I was at an event recently in Offaly where it struck me that the model might easily transfer to the Traveller community. I am referring to a specific men's shed model for the Traveller community. It is an idea.

Mr. John Meehan

I agree with the Deputy. The NOSP completed a piece of research on middle-aged men and mental health. One of the outcomes referred to that socialisation and integration with other men, in particular, and the challenges we have. I recall watching an RTÉ programme where members of the Traveller community went to a men's shed and found it very difficult. I agree with the Deputy that we need to tailor a specifically-targeted model to the Traveller community. It is something that would be worthwhile pursuing and we will look at.

Deputy Joan Collins has some further questions.

Returning to the ethnic identifier, this was a specific issue within the Traveller community when its representatives spoke here earlier about the need for its introduction. I am aware that there is a conversation beginning with the coroner. It is important that that conversation is moved along sensitively but quickly. We need to be able to identify where the issues are within the health service, the mental health services, and the CSO in order to change this.

The Irish Traveller Movement told this committee that although 16% of the community live on halting sites, the records are based on accommodation. Some 84% of Traveller people are not part of that halting site group and cannot be identified as such to their health service.

The Irish Traveller Movement also raised the question as to why the Traveller health advisory committee has been dormant for some years. Will that committee be reinstated, and if so, when? The movement would see that as a serious part of their voice is respect of mental health services.

The Carlow-Kilkenny health project and the liaison nurse mentioned by Dr. Keogh are very interesting. I agree that this seems to be the key in providing access to the services for the people; once the services are there. Was that particular nurse - without giving too much information away - from the Traveller community?

Dr. Brian Keogh

No, she had a background in community health and had worked in a children's organisation and came with a huge knowledge of community services and approaches, which helped her to work with the Traveller community more effectively.

It is important, in the context of the provision of services in different areas, that this model of a liaison nurse to link in with those services be considered by the HSE.

The other point made was about the attitude of "nothing about us without us". That has to be the key call here, namely, that nothing about the Traveller community is to be proceeded with without that community. If we can establish that as an indicator, we can move on from there.

Mr. John Meehan

On the CSO data, that conversation, which is an international one, has to be moved along. That has to happen for both Traveller groups and for other priority groups mentioned in our strategy, which have similar concerns to those alluded to today by the Deputy in respect of the Traveller community. In the NOSP, we are looking at a reflective view of coroner files. The learning from that will engage and develop the conversation further. I am unsure if it has happened as quickly as we all would have liked but rest assured that conversation has to happen and there is an international movement to do so.

The Department of Health might deal with the Traveller advisory committee question.

Mr. David Maguire

This committee was in the Department for a number of years. The feeling was that it was superseded by the Department of Justice and Equality's committee. This committee's remit was more on the social inclusion side than on mental health, because it is broader than mental health. A review was conducted approximately three years ago to determine whether it should be reinstated within the Department and the view was it should not. My colleague from the social inclusion office will be appearing here next week and perhaps he will give the committee more detail on that review, if the committee so wishes.

There are strong views about that reinstatement.

Mr. David Maguire

I understand that.

I imagine they will be raised again. The submissions do not agree with the decision that was made.

Mr. David Maguire

I can certainly bring it to my colleagues' attention in advance of next week's meeting.

That would be helpful. I thank Mr. Maguire. I call Ms Mitchell.

Ms Kate Mitchell

I thank the Chairman for her comment on the ethnic identifier. I would like to bring the committee's attention to a much broader gap in mental health services in that we currently have no national mental health information system. We have a limited set of key performance indicators, KPI, which the services collect data about, including some information on waiting lists and so on. Not having a full and comprehensive KPI suite and data collection is a fundamental issue with regard to what is happening in our services, especially in our community mental health services where the bulk of need is met. We do not know how many people from ethnic minority communities, including the Traveller community, access our services. We lack KPIs for the quality of service provision and outcomes for people using those services. It is completely unacceptable that we spend approximately €1 billion on mental health service provision each year and we do not have a national mental health information system, including KPIs on ethnic minority groups.

Mr. John Meehan

To answer the question posed by Deputy Collins, one of the actions set out relates to the HSE and other relevant bodies, in consultation with Traveller organisations and other stakeholders, working towards a phased incremental implementation of a standardised ethnic identifier across all administrative services. This goes beyond the coroner and the implementation of that. The Department of Health and HSE are co-operating with the Department of Justice and Equality's roll-out of a standardised ethnic identifier. Implementation of ethnicity recording is an action in the forthcoming HSE intercultural health strategy. We cannot look at this in splendid isolation; we have to look at it collectively with all the priority groups. It is identified as an action and is being progressed as such. I apologise that I did not allude to that earlier.

Mr. Meehan is head of the NOSP. How good a job does he think is being done to prevent suicides among the Traveller community?

Mr. John Meehan

I have to reflect on presentations to the committee from this and the previous two meetings. We have to listen to the stories. Suicide has a significant impact on any community, individuals and family members, particularly among prioritised groups, with the stigma associated with it. We need to work collaboratively on education, training and specific cultural training. Senator Freeman alluded to it earlier. I recently spoke to colleagues from New Zealand and the USA. The research shows that we have to provide training, even including undergraduate nurse, medical, psychology or social work training on cultural competency, especially relating to Travellers. It has to start with education in schools.

The Chairman asked specifically about Travellers. The statistics do not show us whether somebody who has died by suicide is from the Traveller community. However, I acknowledge the reports and the feedback to this committee. There are 17 local Connecting for Life plans. The needs of my home county, Donegal, are different from those of Dublin. It is important to tap into the information and knowledge there. One has to recognise that there is much input and we have an action plan for Connecting for Life.

Statistically, the rates of suicide are reducing and I cannot give a specific reason that is the case. We do know, however, that rates have increased among middle aged men, whereas during the recession they increased among younger people.

There seems to be a trend emerging among young women in the Traveller community. We had an experience of this in real time. While we wait for the coroner, as we must, we must pay attention to what people are telling us in the here and now.

Mr. John Meehan

I have acknowledged that, but it is also important that there be an input at local level in order that we can target services and supports in the community in real time. There are 17 local area plans and 17 committees, with a Traveller input in the majority of them. It is important to forge these links at local level in order to obtain real time information. However, we have to rely on coroner data which are reflective of the position over several years and, therefore, retrospective. That presents a real challenge. It is not only a challenge in Ireland; it is one that is also recognised internationally.

Are the 17 groups adequately resourced? There has been considerable praise for the primary healthcare projects for Travellers throughout the country. do they have sufficient resources to do the job they are being asked to do? Would the office be open to accepting the committee's interim report which we will produce in a matter of weeks in terms of resource allocation in 2020? There is urgency attached to the issue. While we wait for the coroners' data and so on, people are in trouble and lives are being lost. Does the office accept and agree with the Minister of State's view that there is a crisis when it comes to Travellers' mental health?

Mr. John Meehan

I will answer the middle question first. As I said in my opening statement, we will work with the committee and accept its interim report. It is very important that it be acknowledged that we are talking and have had an open and frank discussion on the challenges. I have to concur with the Minister of State that there are real challenges when it comes to Travellers' mental health.

Does Mr. Meehan accept that there is a crisis?

Mr. John Meehan

I have to accept that there is a challenge. We have to act on the data provided for us, but the real time information, as the Chairman described it so well, which has come through in recent sessions is also important. We must work on it. It is also important that we work collectively at local level. Our office has a national strategy, but it will only be implemented through the local area plans. There are good examples, on which I touched in my opening statement, of where we have worked positively at local level and provided funding. The funding for the National Office for Suicide Prevention has increased from €7 million in 2012 to €12 million. We are distributing it not only through national NGOs but also in local areas. It will help to inform the local area plans.

What seems to be a lot of money may not be enough to meet the scale of the crisis. As the Minister of State mentioned, there is a mixture of resources available and a willingness on the part of the NOSP and the Minister of State to look at the committee's recommendations in the here and now, as well as long-term issues such as ethnic identifiers, coroner reports, the verification of suicides and so on. Mr. Meehan mentioned the importance of collaboration at local level, but collaboration at national level is also important.

Mr. John Meehan

Yes. It is important. Particularly with reference to Connecting for Life, nationally we report back to a Department of Health steering group chaired by an assistant secretary.

Is there a Traveller on the steering group?

Mr. John Meehan

Actually, there is not.

Would Mr. Meehan be open to having a seat reserved for a Traveller?

Mr. John Meehan

That is something we can consider.

All other Departments involved in Connecting for Life, including the Department of Health, the Department of Justice and Equality and the Department of Education and Skills, are involved in it. I agree that, through the chairman of the group, we need to consider expanding it. The NGO sector is represented. As Senator Freeman said, having a public representative at national level would provide support in that regard.

Absolutely. We will have a report coming out shortly in which we will be making some recommendations. We had a very extensive public consultation process in the Seanad on democracy and participation. It is great to receive endorsement. A Traveller culture and history Bill is being taken tomorrow; therefore, there are many interconnecting measures. I appreciate the reflections of the delegation.

Mr. John Meehan

If it would be helpful, I could provide the committee with an update on Traveller-specific interventions in each CHO. It would give an overall view of what the HSE provides and supports at local level.

I accept that there is a lot going on, but I question whether it is enough in the face of a crisis.

Mr. Meehan said the majority of the 17 Connecting for Life committees had a Traveller voice. Why do the whole lot not have a Traveller's voice?

Mr. John Meehan

I cannot answer that question, but I will try to get an answer to it. If the Deputy asked me which committees did not have Traveller representation, I would not be able to tell her at the minute, but I will endeavour to get the information for her.

I thank everyone for his or her contribution. I hope my question is not stupid. If a member of the Traveller community decides to approach mental health services, can he or she be confident that the person opposite him or her will be a member of the Traveller community?

Dr. Siobhán Ní Bhriain

Could he be confident that the person opposite would be what?

A member of the Traveller community.

Dr. Siobhán Ní Bhriain

If a Traveller were to approach mental health services-----

Dr. Siobhán Ní Bhriain

We could not say for definite that the person within the mental health services would be a member of the Traveller community. Mental health services are geared towards everybody in the community, but we are increasingly recognising that this might not necessarily be enough. Of the groups we look after with mental health disorders, some are marginalised. We recognise this and take steps to deal with it. The committee is a very good step in that direction. Raising public awareness is the first step towards cultural change. Mental health services are very much geared towards helping whoever presents to them.

Ms Kate Mitchell

Following on from the previous comment, the information on the number of staff members in mental health services who are from various ethnic minority groups is not available. There really is a need to recruit mental health staff from various ethnic minorities, including the Traveller community. One of the recommendations in the mental health report and the guidelines, published in collaboration with the Mental Health Commission, emphasises the recruitment of staff from various ethnic minorities. We urge the committee to consider this in making its recommendations.

Dr. Aileen Tierney

The Traveller counselling project is led by Mr. Thomas McCann who comes from a Traveller background. Where there is no specialist service available, there should be cultural consultation with organisations that are Traveller-led and sensitive to the Traveller cultural background.

That is interesting. I commenced work on so-called gay conversion therapy and believed the practice was apparent just in rogue groups, some north of the Border and some within the Catholic Church. To my horror, there was a Trinity College Dublin report on negative experiences of mental health services among LGBT people. Obviously, there are lingering effects from criminalisation and homosexuality being in the diagnostic manual until approximately 1973. I wanted to get a sense of whether we should prioritise the recruitment of Travellers to be mental health professionals or the training of health professionals.

From my experience, there may be people within the mental health services who have never gone through retraining or upskilling. Is it too late when they are already with the HSE for this? Is there constant retraining or is it too late after their education to-----

Dr. Siobhán Ní Bhriain

The Senator has made a number of points there but I will return to the first thing he mentioned, which was conversion therapy for people who may not have gender-congruent orientation. That is absolutely unacceptable and is not part of the mental health services. It is not an evidence-based therapy or something we would accept in any way.

The point that the Senator is making is that we know that but we are also querying the competence of anybody to whom a member of the Traveller community might be referred, where they might be met by a therapist from the health services or outside of them who is capable of treating that person as an equal, and does not hold prejudice or discriminate, in a hidden manner or not. I am encouraged but sceptical of Dr. Ní Bhriain's confidence that our current mental health services are in that state.

Dr. Siobhán Ní Bhriain

I will mention something specific about conversion therapy because I was asked that question recently and I circulated the entire national clinical leads group on that particular front. It is not acceptable.

On the issue of training and discrimination, I would hope that people will not be met with prejudice. It is very important to emphasise that through my own clinical career - it has been relatively long since I started out - people with mental health disorders were very marginalised and stigmatised. That beginning to change. It is very important that within that, we are culturally sensitive to the highly diverse ethnic groups that we see, including the Traveller community. Ongoing training for us as professionals is mandatory. We are obliged to do it by our regulatory authorities and we continue to do this, through both our regulatory authorities and professional bodies. This is very much part of what we do. It is never too late because we have to do continuous professional development throughout our careers.

Given the scale of the crisis, we need to be doing better than hoping that the person one might be referred to has cultural sensitivity.

Dr. Siobhán Ní Bhriain

I absolutely agree with that.

I call Deputy Corcoran Kennedy to speak now.

I wish to pick up on the request - I am unsure whether the HSE have agreed to this - to send the committee information on the CHO areas as to what exactly is happening in each of them. This would be very helpful to us.

Can the HSE also comment on whether it has enough resources to do what it needs to do? Are there any other questions, queries or comments?

Ms Kate Mitchell

In one final comment, people in the room are quite aware that Mental Health Reform is quite concerned about the mental health budget for 2020. While more than €1 billion has been allocated to mental health services, that funding is allocated to keep services ticking over and operating as is. Of some €39 million in additional funding, €26 million of that is going towards pay and other associated issues while the remaining €13 million is going towards the new forensic mental health service development in Portrane, which is opening next year in 2020. Our real concern is that there is no new additional development funding for 2020. That is really key and significant in the context of these discussions. If we are going to improve services, we need to see the funding and the resources allocated to make those improvements.

People will also be aware of the dissolution of the mental health director office and the mental health division in early 2018. There are real concerns that in the absence of that post and office, there is that lack of oversight and leadership in driving the necessary reforms onwards. These are two really key issues-----

They are broad points.

Ms Kate Mitchell

-----which relate to the development of services.

We have to stick with the focus we have here on this committee, which is, specifically, the crisis in Traveller mental health and the responses to it.

Ms Kate Mitchell

I think it is related with regard to driving those developments forward.

Dr. Aileen Tierney

It is important that we focus on mental health. Mental health is an individual discourse at times but we need to remember to embed equality across all social infrastructure. While I did not address education so much today, if we do not look at access to education and employment, as well as inequality in societal infrastructure, we are not addressing where the difficulties in mental health come from. They do not just come from the individual but also from societal inequality.

I thank the witnesses. We will look at health in the next two meetings, we will have four meetings about education, then we will look at employment. We will come back to accommodation, since having a safe, decent place to call home seems to be a fundamental part of being able to be well. Do any witnesses have any final points?

Mr. John Meehan

Connecting for Life identifies Travellers as a priority. I do not want to leave today without reassuring the committee and people listening that we recognise that Travellers are an ethnic group with a distinct culture. Travellers have specific health needs that we have to identify and they require a health service that is responsive to their needs. I would like to reassure the committee that we are progressing with that frame of mind about Travellers as a priority group within mental health services.

That is encouraging and a good note to finish on. It is heartening to hear that the Minister of State, the Department and the HSE, which is the main delivery agency for health and mental health, all recognise the crisis and prioritise it. That will be judged by the actions that we take. As we wait for coroners, ethnic identifiers and such, people are dying, lives are being lost and families and communities are in crisis. We have no time to waste on this. We cannot afford complacency. I thank all of those who attended today, including Dr. Tierney, Dr. Keogh, Ms Mitchell from Mental Health Reform, as well as the witnesses from the Department of Health and the HSE. I am anxious that this report will stimulate action to address the crisis in Traveller mental health.

We will adjourn until 11 a.m. on Tuesday, 22 October 2019, when we will open our consideration of the topic of health.

The joint committee adjourned at 12.58 p.m. until 11 a.m. on Tuesday, 22 October 2019.