Joint Sub-Committee on Mental Health díospóireacht -
Tuesday, 18 Apr 2023

Life Cycle Approach to Mental Health: Discussion

An Cathaoirleach

The purpose of the meeting today is to consider the issue of the life cycle approach to mental health, particularly in the context of older people. To enable the sub-committee to consider this matter, I am pleased to welcome Mr. Seán Moynihan, chief executive officer, Ms Gráinne Loughran, senior policy and advocacy officer and Mr. Frank Dillon, head of communications, from ALONE; and Mr. Mervyn Taylor, chief executive officer and Ms Róisín Clarke, programme adviser from Sage Advocacy.

All those present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19.

Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any other person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses, or an official either by name or in such a way as to make him or her identifiable. Parliamentary privilege is considered to apply to the utterances of members participating online in the committee meeting when their participation is from within the parliamentary precincts.

There can be no assurances in relation to participation online from outside the parliamentary precincts. Members should be mindful of this when they are contributing. Members are also reminded of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any members partaking via Microsoft Teams to confirm that they are on the grounds of Leinster House campus prior to making a contribution to the meeting.

I invite Mr. Seán Moynihan to make his opening remarks.

Mr. Seán Moynihan

ALONE welcomes today’s discussion on mental health in the context of older people and believes that focus on this area is overdue. A significant proportion of older people experience mental health difficulties. Unfortunately, they are under-recognised, underdiagnosed and undertreated. Evidence suggests that there is a severe mental health crisis among older people that is not being captured by HSE and Department of Health figures. Mental health difficulties among older people are under-recognised by the medical profession and by older people themselves.

The Irish Longitudinal Study on Ageing, TILDA, research has shown that 78% of older adults who have evidence of depression and 85% who have evidence of anxiety do not have a doctor’s diagnosis. This is supported by ALONE data. The number of interventions to support mental health carried out by ALONE has increased by almost 300% in the past year. In quarter 4 of 2022, 29% of the 1,926 older people we assessed for our services identified they had issues relating to their mental health, but over half of these had not attended a GP for support. The Sláintecare implementation plan for mental health needs to incorporate findings from sources such as ALONE, and to work to capture and address the under-reported mental health crisis that exists among older people.

We do not give older age due consideration as a time when mental health difficulties may emerge for the first time. We do not discuss how the ageing process is associated with age-specific psychosocial risk factors for mental health difficulties, such as living alone, bereavement, physical illness, disability and cognitive decline. Without this discussion, sufficient preventative and supportive measures are not in place in community and health services.

Other social determinants of mental health relating to areas such as the cost of living and the ongoing housing crisis are also extremely important. For example, CSO data indicate that older people are among the groups most impacted by the increased cost of living. We know that considerable anxiety is being felt because we hear about it when older people call ALONE’s national support and referral line after they have received bills they cannot pay.

Mental health problems experienced by older people often reach crisis point before intervention is made. For example, our staff do considerable work around supporting older people with decluttering and hoarding, often to enable safe hospital discharge. At times, this is so severe that other services, such as social workers and home support workers, will not enter the older person’s home because of the risk to their own health. Hoarding poses a physical risk, but is often the result of psychological ailment. Generally, there is no service other than ALONE that will support an older person with this process. Organisations such as ALONE that work to mitigate the impact of risk factors relating to mental health difficulties for older people must be adequately supported to do so.

A central issue is the continuing impact of the Covid-19 pandemic and, specifically, of cocooning on the mental health and loneliness levels among older people. This cannot be overstated. ALONE assessed 1,926 older people for our services in quarter 4 last year. Among this group, 70% reported that they felt lonely. More than one in ten, 11%, reported that they had not been out socially for at least a year. A further 8% reported they had not been out socially in the past six months. As half did not record a response to this question, the true numbers may be even higher.

Increasingly, we are working with older people who have completely cut themselves off from their families, friends, communities and life in general due to fears about Covid-19 that have not subsided. Many were healthy and active prior to the pandemic. As a country, we put significant effort into telling older people to cocoon and stay inside. We offered them support to do so, but we have not done the same to support them to re-engage with their communities.

We need to identify and implement precision research-backed interventions for the loneliness and social isolation that is impacting this group and all other groups affected by loneliness.

As co-founders of the loneliness task force, we have called for an action plan to combat loneliness and social isolation across all age groups for years. Development of the action plan was committed to in the programme for Government, the roadmap for social inclusion and the Healthy Ireland strategic plan. It has still not been completed or, as far as we can gather, even started. We have been told by the Department of Health that it is struggling to find a resource.

Loneliness and isolation impact physical, mental and brain health. Loneliness and depression are closely linked and loneliness leads to outcomes like increased risk of dementia, early mortality and cardiovascular illness. Loneliness also has strong links to psychosis and schizophrenia and TILDA research has shown it is strongly linked to the wish to die among older people. We have quoted repeatedly the research that shows that loneliness has been shown to have as severe an impact on our health as smoking. Why does it not receive the same public health response?

ALONE believes our experiences highlight the gaps in mental health policy and provision for older people and the lack of joined-up thinking across mental health supports. The Sharing the Vision plan has specialist groups set up to progress recommendations for youth mental health transitions, acute bed capacity, women’s mental health, primary care and digital mental health. The impact of Covid-19 on the mental health of our older population has been repeatedly noted yet there is no specialist group for implementing the Sharing the Vision recommendations for older people.

Furthermore, Sharing the Vision recommends the development and implementation of a range of actions designed to achieve the goals of the national positive ageing strategy for the mental health of older people. While this is a positive action, we cannot see that any new work is being done to achieve it. A list of actions has not been published and the implementation plan cites previously established examples, including ALONE’s own work, as evidence that this recommendation is being progressed. We do not believe that this demonstrates sufficient commitment to progressing mental health supports for older people.

I would encourage everyone present, if they have not done so, to read the Mental Health Commission’s report on services for older people published in 2020, which more fully outlines the gaps in mental health provision than I have time to do here. Unfortunately, we cannot find that things have radically changed since the Mental Health Commission’s report.

We are still waiting for the pilot of the model of care for specialist mental health services for older people to begin. The model was published in 2019. The Sharing the Vision implementation plan from quarter four of 2022 reported that four pilot sites have been identified and others progressed but this is taking too long. Meanwhile, the HSE’s 2023 service plan reported expected 2022 activity for the number of psychiatry of later-life referrals seen by mental health services at 7,965. This is a total of 1,060 people and 12% below the expected activity.

A Dáil debate took place in April two years ago on Covid-19, mental health and older people. Many positive ideas were discussed and not progressed. We believe that significant action on mental health difficulties being experienced by older people is urgently overdue. We would like to make a number of recommendations.

Specific mental health policy, evidence-based programmes and research for older people must be committed to, funded and implemented as part of Sharing the Vision. These should be developed in collaboration with experts and stakeholders working with older people. The action plan to combat loneliness and social isolation must be completed, funded and committed to, including funding for Irish research, and older people must be provided with additional supports to re-engage with their communities in collaboration with experts and the community and voluntary sector. Organisations that enable the mitigation of risk factors for mental health in older people should receive sufficient support.

Mental health for older people is a hugely diverse area and I do not have time to address several key areas, including the roll-out of social prescribing; the need for safeguarding legislation; the assisted decision making legislation; the positive impact of ALONE's support and befriending services on the health impacts of loneliness, which was evaluated through the HALO project; our research and pilot activities in mental health, including online counselling solutions for older people, in partnership with Helplink Mental Health and Mental Health Reform; the reform of the Mental Health Act; and importantly, the voices of older people experiencing these difficulties.

We are happy to discuss these matters further at any time. I thank the committee for its attention.

Mr. Mervyn Taylor

Sage Advocacy welcomes this opportunity to make a submission to the Joint Sub-Committee on Mental Health. We thank members for this opportunity. I am joined by my colleague, Ms Róisín Clarke, who was a founding member, with me, of Sage Advocacy and was, until recently, interim CEO of Mental Health Reform. Sage Advocacy is the national advocacy service for older people. We also support vulnerable adults and healthcare patients in certain situations where no other service is able to assist. We provided information, support and advocacy to almost 5,000 people in 2022 and our work on behalf of clients is independent of family, service provider and systems interests. We ensure that people's voices are heard, their wishes are taken into account and they are assisted, in whatever ways necessary, to be involved in decisions that affect them. Our motto is simple: "Nothing about you without you".

In the course of our work, we engage with clients and family members who have mental ill health and sometimes considerable mental illness, but we do not believe, as we are currently structured, skilled and funded, that we are capable of being the sort of dedicated advocacy service that people with mental health difficulties require or deserve. Owing to the nature of our work, we see mental health in older age as less about the provision of clinical services, important though they are, and more about the causes of stress for older people as they face into the challenges of later life. I will cite some examples of these challenges. One is family members taking possession of their home when they are in hospital. It is not uncommon for Sage Advocacy to have to assist people to regain possession of their own home arising from the actions of avaricious relatives. It is hard to believe but it happens far too frequently.

Older people are shoehorned into nursing homes for a period of convalescence following an illness and then funding is organised through the nursing homes support scheme without the clear consent of the older person. In other words, older people are sent to limbo and may be deprived of their liberty in a place of care. Another challenge is deprivation of liberty in places of care arising from the views of health and social care professionals, a shortage of home supports and a bias towards care in congregated settings such as nursing homes. The use of convenience medication, which is a nice term for chemical restraint, and incontinence wear to ease work pressures associated with shortage of staff and unwillingness to support older people with continence issues in the community, and insisting that the care can only be provided in a congregated care setting, that is, a nursing home, is a challenge. Health services in the community are already inadequate, including mental health services, and are not available to people in older age, especially in congregated care settings, and there is poor clinical governance in congregated care settings despite strong recommendations by Sage Advocacy and the expert group on nursing homes which reported in 2020. There has not been sufficient progress following the report of the expert group on nursing homes and the recommendations about clinical governance in nursing homes.

A considerable source of stress arises from widespread confusion regarding the status of next of kin. This creates an incredible number of rows within families and with service providers. Next of kin simply means someone who people would like to be contacted in an emergency. Being a next of kin provides no legal standing whatsoever despite widespread belief to the contrary. A RED C public opinion survey in 2018 found that 57% of people believed that next of kin was someone who can make healthcare decisions about them if they are unable to do so. That is a frightening figure. Equally worrying was that 32% of people believed that next of kin was someone who can access their bank accounts and assets they are unable to access.

The issue of next of kin is closely tied in with another key issue facing older people, namely, safeguarding. Sage Advocacy looks forward to the long-awaited report of the Law Reform Commission on a legislative framework for adult safeguarding.

We strongly urge this committee to support the establishment of a national adult safeguarding authority, preferably under the aegis of the Department of Justice. This would reinforce the point that adult safeguarding is a rights-protecting and enhancing practice which needs an interdisciplinary approach involving social work, healthcare, policing, financial and research skills. The Adult Safeguarding Bill was brought forward in 2017 and despite having all-party support, it has not progressed through the Oireachtas. I understand that the Cathaoirleach has a particular personal interest in the issue and we appreciate that.

When the report of the Law Reform Commission is published, this Adult Safeguarding Bill should be progressed with all necessary speed. In the meantime, a simple change to existing coercive control legislation to allow it to relate to people in non-intimate relationships would be helpful. In 2015, the expert group review of the Mental Health Act 2001 recommended a range of advocacy supports including both peer and representative advocacy as a right for all individuals involved with the mental health services. The commencement of the Assisted Decision-Making (Capacity) Acts, effectively next week, and the operationalising of the Decision Support Service under that legislation, planned legislation to protect the liberties of people in places of care and the long-awaited report on a legislative framework for adult safeguarding from the Law Reform Commission will all contribute to a growth in demand for independency advocacy services.

Sage Advocacy asks the Sub-Committee on Mental Health to address this emerging need for independent advocacy and the related need for appropriate structures, funding, training and co-ordination through the establishment of a national advocacy council.

The life cycle approach to the challenges of older age is an important one, which is informed by older people’s actual experiences as they move further along the life cycle. A lessening of physical abilities and decision-making capacity associated with older age requires not just the provision of the more easily understood supports and services such as home help, transport, social clubs, day centres, meals-on-wheels, respite care and congregated care but also investment in supports and services which can assist older people as they experience cognitive decline, avaricious relatives, coercive control, emotional and financial abuse, legal problems and the provision of services in a manner that suits service providers and reproduces institutional approaches.

The interplay between mental health, chronic illness and older age requires that we ask questions about how effective the life cycle approach is and how well it is being implemented. For many older people the support and service options available to them decrease as they grow older. There is still a clear bias towards care in congregated settings; places in which weak clinical governance and the dangerous architecture of the nursing homes support scheme combine to restrict access to necessary services. It is really important to understand that at the end of the life cycle, people in a nursing home are there for an average of two years. It is the last period of their lives and the services, limited though they might be in the community, are very often extremely hard to get because they are seen as being cared for in this congregated setting. In planning for the new regional health authorities which are going to emerge in the next few months and will officially be up and running from 1 January next year, it is vitally important that mental health supports and services are planned for across the continuum of publicly funded services, including where they are privately run.

An Cathaoirleach

The Mental Health Commission sent the committee a paper. I will read out the conclusion:

Older people’s mental health is an increasingly important area of public policy that does not always get the attention it deserves. As set out in the [Mental Health Commission's] 2020 report older people’s mental health services particularly benefit from an integrated approach with social care services and close working relationships with primary care and community services. The [Mental Health Commission] recommends that the findings of its 2020 report are used to inform public policy in this area.

I thank the Mental Health Commission for sending that in.

Senator Martin Conway

It has been quite frightening to listen to the two opening statements regarding the issues and the day-to-day concerns, outside of the more serious concerns.

It is frightening to think people are being put into nursing homes somewhat against their will or coercively, with the fair deal scheme being applied for without their full consent. While there are recommendations for dealing with that, I have a few questions about it. Have the organisations before us engaged in any extensive way with the HSE regarding the practicalities of the operation of the fair deal scheme and the potential difficulty in that regard? In the scenario I outlined, persons are coerced into a nursing home and the fair deal scheme is applied for on their behalf. Are there any checks and balances to ensure their signatures are authentic and properly witnessed, with all the necessary steps taken?

My next question is for ALONE. Pre-pandemic, there were challenges and post pandemic, there are significantly more. What is the funding structure of the organisation? Is it well funded? Is it funded by the HSE or how is it funded to complete its important work? During the pandemic in particular, ALONE had a high profile in terms of the supports it provided. As its representatives rightly said, people were advised to cocoon and for good reason, but there is not the same emphasis on people now re-engaging in society. That information campaign should be driven by the likes of ALONE as opposed to the State. Does the organisation have funding in place to do that and is it doing it? If not, is it willing to do it? What is the overall funding structure for the important work ALONE does, given ours is an ageing society?

Mr. Mervyn Taylor

In regard to the nursing homes support scheme, which some people call the “fair deal scheme” and others call the “unfair deal scheme”, while still others say it is just a "deal", there are different views on it. It is certainly fairer than what was there previously.

I said the architecture of the scheme is dangerous. The nursing homes support scheme starts with one building block, namely, the National Treatment Purchase Fund. People who buy hip replacements and all sorts of other clinical medicine procedures negotiate individually with nursing homes - I use the term "negotiate" in inverted commas - and the nursing homes decide what rate they will pay. The HSE has no say. Approximately 80% of nursing home provision is now in private hands, with only 20% in public hands, although that is a simplistic statement that might be off by one or two percentage points. The HSE administers the scheme but does not have any other control of it. HIQA, which inspects rather than regulates, does not set the terms of the contract or the way in which people are admitted to nursing homes. ComReg, for example, might have a role in deciding the price of the band within which a mobile phone operates. I am getting out of my depth because I am not an expert in communications regulation but the Senator will understand the point I am making.

Senator Martin Conway

Absolutely.

Mr. Mervyn Taylor

HIQA, as the regulator, does not have any say in, for example, the style of the contracts or the way in which they are signed. It can raise some questions but it is not truly a regulator, in our view. Placement in a congregated care setting is a grey area. Someone could have delirium and be recovering from it in an acute hospital after, say, a urinary tract infection and that can take some time. The patient might be developing some signs of cognitive decline but could nonetheless be recovering within the overall framework.

The patient may go for a period of time into a nursing home. That does not necessarily mean anything. The patient may think or may have been told that he or she is going there for convalescence, to use the old phrase, which is still relevant. The family members may have a different view. They may well think it is in the person's best interests that he or she should be there.

Senator Martin Conway

It is a kind of a covert way-----

Mr. Mervyn Taylor

It is a covert way.

Senator Martin Conway

-----of introducing it to the person and hoping he or she will like it and agree to stay.

Mr. Mervyn Taylor

Absolutely. Then, the person waits for a month and then another month.

Senator Martin Conway

Wait until the weather improves.

Mr. Mervyn Taylor

We have examples we can provide before we leave. We will provide the Senator with some good case examples all written on a postcard to help him understand them quickly. There are people who have left nursing homes who were told they could not leave or the Garda would be called. There are not that many but the fact of the matter is that the process of going into care is a grey area.

There are improvements coming, one of which, and we would ask for pressure in this regard, is the protection of liberty and places of care safeguards. There is a law that provides that nobody can be detained except by the rule of law but there is actually no law for places of care. There are Supreme Court rulings regarding a case in Cork University Hospital, CUH, a couple of years ago that have made that particularly important.

There are also placement forums, which are only now being properly developed within the HSE. There is also a tool called InterRAI, which is basically a holistic assessment, including capacity assessment, physical needs and social needs. That, in a way, identifies the need for care support in the community or perhaps in a congregated care setting. There is a shortage of home care supports, which is one problem. It is so easy because the money is there in the nursing homes support scheme. We have still not got these mini-institutional types of approaches out of our heads. I have to say this very clearly. We have seen cases whereby people who are now effectively detained in congregated care settings could, for one third of the cost, be living in their own homes with a level of support.

Senator Martin Conway

Absolutely.

Mr. Mervyn Taylor

Yet, there is a real problem of professionals in some cases not being willing to go into the homes of older people because they regard them as insanitary. They do not want to go in to them and say nursing home care is required, which is what sets the whole thing in train. We have, therefore, a systemic and professional issue. We need legislation to protect the liberties of people in places of care.

Senator Martin Conway

I believe Deputy Colm Burke has drafted a Bill in this area. From the mental health perspective, it is obvious that all those factors - involuntary detention and so on - have a seismic affect on mental health.

From this committee's perspective, we will be drafting a report. We would love to achieve everything but we probably will not. What we need are maybe two or three clear asks in our report that would make a difference and improve things if implemented by the Government. If we were to ask Mr. Taylor for two or three key recommendations that we can put into our report, what would they be?

Mr. Mervyn Taylor

One would be a commission on care, which has been talked about for some time, but not just that in itself. The commission on care should look at the entire structure and working of the nursing homes support scheme. There is a systemic bias towards care in congregated settings, which we must end. That is one issue. The second is the protection of liberties in places of care so that there is a due process of law before anybody is effectively detained. To one person it is care but to another it is custody.

Senator Martin Conway

Yes.

Mr. Mervyn Taylor

There has to be due process. Nevertheless, care in congregated settings is needed in some situations.

The third issue is to have safeguarding legislation. The Law Reform Commission report is long overdue.

The safeguarding Bill must be put into effect because that will give us something with which to pursue some of the really difficult cases. People are falling between the cracks and we need a much stronger safeguarding approach. The commission on care, the protection of liberties and safeguarding legislation are three elements. There are more than three, but the Senator asked for three and therefore got three.

Senator Martin Conway

I am sure there are more. I thank Mr. Taylor. Could I hear from ALONE?

Mr. Seán Moynihan

I will address the first issue quickly because Mr. Taylor has covered much of it. On the fair deal, in some ways there are certain drivers behind people going into nursing homes. There seems to be much emphasis on getting access to older people’s houses when they go into nursing homes, especially because, unfortunately, they tend to live only for around two more years when they enter one. Most people, on moving into a nursing home, have no desire to become a landlord. It creates an environment where people are put under stress or pressure, possibly from family, to rent out the home, especially because doing so has become more lucrative. In some ways, the houses will come back on stream. In that case, we should focus more on other housing options.

We have been working with the Department of Health and the HSE on this. We are an approved housing body. Ultimately, we have been championing housing with support as an alternative to nursing homes. I refer to 24-hour support on site, with a universal design. People would have their own front door and much more autonomy. The first example, funded by the Government, will open next June. It is a matter of creating scalable, replicable examples across the country to ease the pressure on nursing homes but also to create more choices for people.

On the second question, pre-pandemic levels of loneliness were always high. We run the loneliness task force. Increasing levels of anxiety, mental illness and loneliness are evident across all age groups. As outlined in our opening statement, there are many commitments to a strategy on loneliness. Its implementation and resourcing are what we are looking for in many cases.

With regard to our funding, we have a mixture of funding sources. Since we are an approved housing body, we have income from housing, but, as with every other organisation, we fundraise. We use funds raised for innovations and to address gaps. Our model of operation – whether it entails housing with support or the provision of training, resources and technology for older people to other organisations – involves our trying to create pilots to fill gaps and then approaching the likes of the HSE and policymakers to scale those pilots that have been evaluated.

Senator Martin Conway

How many houses does ALONE have?

Mr. Seán Moynihan

We have around 160. There is a focus on older people and persons with disabilities. We have housing for older people and we provide them with off-site support but our strategic pivot going forward is the development of housing with on-site supports, thus creating a wider choice for older people rather than just offering nursing homes.

Senator Martin Conway

Is there a model in existence that Mr. Moynihan would say is ideal?

Mr. Seán Moynihan

I believe there is. We have learned a lot from the project we have been working on for the past five or six years, and we are trying to engage with the Department of Health, the HSE and the Department of Housing, Local Government and Heritage to discuss this matter, having regard to a universal design and people having their own front door, staff on site and access to food. On the latter, it is more about people’s choices around food and their autonomy. We have created the model or a demonstrator. There is significant market interest in funding these types of things. Investment funding would not just come from the Government. It is something we can create a breakthrough on.

Senator Martin Conway

I presume ALONE focuses on town-centre locations.

Mr. Seán Moynihan

That is what we want to do. If we can build housing with support within town centres in rural areas, we can actually bring pensions into those communities and also keep older people in the hearts of the communities where they want to be.

Senator Martin Conway

Absolutely.

An Cathaoirleach

The next speaker is Deputy Lahart, who is joining us online. Will he confirm he is located on site in Leinster House?

Deputy John Lahart

Yes, I am in my office. I thank the witnesses for their presentations. I practised as a psychotherapist and I have a particular interest in mental health. I was taken aback by some of the content of the presentations. I thank ALONE, Sage Advocacy and the Mental Health Commission for forwarding papers to the sub-committee. Any Oireachtas Members or members of the public listening in will be particularly taken by the discussion on the huge impact of the Covid period on people's mental health. As public representatives, we certainly are aware of that, including by way of the weekly stories we hear about the impact on older people in particular and how deeply and quickly embedded the behaviours that were associated with the Covid crisis have become in their life patterns.

Reference was made to loneliness, how people did not receive visitors for a long period and how frightening the whole Covid experience was for many. As a society, generally speaking, we seem just to have moved on from that. I referred once or twice in the health committee during the Covid period to a great book called Stacking the Coffins, which is not a very positive title. It is about the Spanish flu pandemic and its impact in Ireland. One of the author's findings was that the failure to commemorate or mark what happened in a significant way meant the impact of the Spanish flu crisis was lost from the Irish consciousness and psyche. As a result and unlike in other countries, when the Covid pandemic hit, we were unprepared for its impact because it had gone out of the collective memory of Irish people that there had been a pandemic here just a century ago. Very few of us knew of the impact of the Spanish flu pandemic in Ireland. I certainly did not. The book - the author's full name escapes me, but her first name is Ida - was one of the first to be written about the Spanish flu experience in Ireland, which made it quite important.

In discussing the life cycle approach to mental health, I am reminded of a phrase my late father used when he was in his last period of life and which I had not heard before then. It was "once a man, twice a boy". It is important to note that some people live the most extraordinary and rich lives right until the end in which they remain very active and surrounded by other people. I would like to think they are in the majority. A dear friend of mine who is aged in their late 80s is one of the most extraordinarily active individuals I have ever met. This person is independently active, has created a full life and keeps a dynamic going. However, as was mentioned, even before the Covid crisis, levels of loneliness, mental stress and challenges around mental health existed for older people.

Mr. Moynihan of ALONE said: "We do not give older age due consideration as a time where mental health difficulties may emerge for the first time." That is particularly interesting. Having practised as a psychotherapist, and as I know from my own life, when people experience a mental health challenge for the first time, which could be around something like a bereavement, it kind of arms them, if they deal with it successfully and with assistance, for further mental health challenges that may arise over the course of their lives.

The idea that a mental health challenge may occur for the first time in someone's senior years is particularly challenging and interesting. Maybe ALONE could say a little more about that.

Mr. Moynihan mentioned the action plan to combat loneliness. What is the status of that and how are mental health services for older people linked, for example, to the implementation of the national positive ageing strategy?

Mr. Seán Moynihan

To reiterate a point a member made, older people are net contributors in society. It is wonderful that a lot of people are living longer and healthier lives but the fact that older people now make up 20% of the population leads us to say that more resources and focus need to come into play, whether in housing, transport or mental health, because the numbers are rising.

As regards the national positive ageing strategy Deputy Lahart mentioned, last month was the tenth anniversary of the launch of the strategy. It never had an implementation plan and no money was ever provided for it. A few years ago, it was changed from a strategy to guiding principles. It has now been rolled up into the commission on care, which Mr. Taylor highlighted. We have been waiting for the commission on care to be set up for several years. Rather than using our time to respond to an ageing population in the areas of loneliness and mental health by planning, discussing and reacting, we are slightly stuck in getting things set up.

The issue with loneliness is interesting. Following Covid, many people are aware of the effect of loneliness, some of which is caused by the fractures of life, death or bereavement. The loneliness task force, on which carers, Jigsaw, the Samaritans and Trinity College are represented, highlighted the levels of loneliness in older people during Covid and the effect of that on their mental health. There is so much evidence to show that loneliness is a predicator of poor mental health outcomes, anxiety, distress and poor physical outcomes. The task force also showed that there is a large number of younger people who are struggling in that area. As an NGO, we formed the task force with people who have knowledge. We have made lots of submissions and extracted all the TILDA research and other research and presented it to the Departments, the Government and others. Despite this, we cannot see where the commitments in the programme for Government, and those made by Healthy Ireland and in the implementation plans, are backed up. We cannot find an individual in the Department of Health who feels it is within his or her remit to discuss loneliness. This is post-pandemic, when we have realised the effect the pandemic had on all age groups and their mental health.

We welcome that the committee is talking about mental health in older people. In the past eight to ten years, mental health has become much more visible to people. It is a topic of conversation. I love phrases such as "It is all right not to be all right." While we are across all these things, we are not targeting older people. We are leaving them out of the conversation. Everything done by the specialist organisations in this area seems to be targeted at young people. For us, it is about the Government and all of us in society living up to our commitments and the evidence we have.

On loneliness, if the commission of care is where the national positive ageing strategy has gone, and we think it has, then we need to get it established so that we have a way of driving this conversation. To repeat myself, we all know how difficult loneliness is. There is so much research to back up its impact on physical and mental health. In reality, there is a need for action across all age groups in this regard.

An Cathaoirleach

Does anyone else want to come in on that?

Ms Gráinne Loughran

Deputy Lahart spoke about mental health difficulties beginning in old age. This is something that causes older people significant difficulty because the symptoms of mental health difficulties are often different when people are older as opposed to when they are younger. There is not significant awareness around that. Increased headaches and arthritic pain can be the symptoms of depression in older age, but this is not recognised. The symptoms are not really discussed. They are not considered in terms of mental health awareness campaigns or raising awareness around mental health difficulties.

Sharing the Vision contains a commitment in respect of the development and implementation of a range of actions designed to achieve the goals of the national positive ageing strategy for the mental health of older people, but there is nothing on reducing stigma or increasing awareness of those symptoms or education around mental health for older people. There is nothing in the context of fully capturing and addressing the level of untreated mental illness among older people or assessing the barriers, of which there are many, that older people experience in accessing mental health supports. There is everything from things like mobility, accessing digital supports, self-stigma and ageism. There is consistent evidence that mental health clinicians are less willing to work with older adults and they have negative assumptions about the effectiveness of psychotherapy. That is from a piece written by Mr. Brian Harvey for the Irish Senior Citizens Parliament in 2022. This is a matter of concern because psychological therapies can be more effective for older people than for those of working age. Ageism is another significant difficulty. For older people experiencing mental health challenges for the first time, a number of barriers can be in place to accessing the relevant supports.

Ms Róisín Clarke

I will add to that. I agree with the points that have been made. The life span or life cycle approach is embedded throughout our policy language and we speak about it but it is only really effective if we follow right through for the entire life cycle. We are falling very short in mental health services for older people in the community, in primary care and in acute services. We need to look at loneliness and its impact in context and at the significant effect that deteriorating physical health has on an older person’s mental health. We really need to look at this matter in a very holistic manner in terms of the integration of services. Services need to talk to each other. It is crucially important that out in the community, social care and healthcare professionals are trained in how to identify mental health issues in older people because the dots are not being connected, people are not being diagnosed and they are suffering as a result.

An Cathaoirleach

Does Deputy Lahart have more questions?

Deputy John Lahart

I would have known professionally how, as a society, we generally still associate loss with the loss of a loved one. While not as acute, loss of status, health or a pet, some materially cherished thing or a home can have a significant impact on people.

Depression used to be the concept that dared not speak its name. Loneliness is a much more difficult thing for people to speak about. I would be grateful if the witnesses could attempt to provide a definition of it that might be helpful for the record, never mind for people who are listening.

I have a couple of questions. I found the concept of hoarding very interesting. I ask the witnesses to say a little bit more about that. ALONE seems to be the only agency that offers assistance to people dealing with this. Where might hoarding emanate from? I refer to the challenges people face in terms of decluttering their lives.

I never liked the term "cocooning". It is easy to forget that the term emerged from the images from Italy at the time of the outbreak of Covid in Ireland. That generated a fear and meant we were not able to give sufficient time and did not have sufficient research available to us to consider things such as the fact Irish people, in particular older people, did not live in the same kind of communal settings as their Italian counterparts. That had a profound impact. The notion of cocooning made a lot of sense at the start, and I do not think anybody rebelled against that. As I said, it shows how deeply and quickly behaviour becomes embedded psychologically. I am aware of a lot of examples of this.

How do the witnesses think we can go about encouraging people and providing messaging? There was brief messaging on this a month or two ago when the new chief medical officer, CMO, addressed the issue. It stands in stark contrast to the very rich lives the majority of older people live on a daily basis and how engaged many older people are in everyday activities. It stands in stark contrast to the number of older people who spend as much time out of their homes on a daily basis as they do in them, doing things and being active, engaged and involved in their communities. Many play a vital role in their communities, rather than just turning up to things that are laid on for them. They provide and lay on things for other people in their communities.

Mr. Mervyn Taylor

On hoarding, ALONE very often refers complex issues of advocacy to us. We also refer complex issues of hoarding to ALONE. One point the committee might like to know is that the safeguarding policy of the HSE does not address self-neglect because it does not see it as in any way related to safeguarding. It says this is to do with resourcing. In fact, there are some ideological problems in the professions. It is a fact that at the moment self-neglect and related issues of hoarding are outside of the HSE. It is refusing to deal with those issues. That is not a matter of policy; it is a policy not to have a policy with regard to that. I want to stress that point.

I wish to make another observation before handing over to others. Deputy Lahart referred to the Spanish flu, Stacking the Coffins and how quickly we can forget. Some of it is there in folk memory, but we need to have something more positive rather than a blame game in regard to Covid.

I think what we need to see is some more world-class demonstrator projects, with the best of architecture and social design, which are around housing with support for older people and younger people - intergenerational - but also new models of congregated care, which are there and being worked on, such as in the household model. For example, if we had some of the household models, we could have had different outcomes in respect of congregated care because we could have had households of around ten or 12 people but the care could have been provided across campus. People could have been able to visit at doors. The isolation would not have been for everybody because a few people had been infected. I am not interested in lots more inquiries. The Government will have one, which is fine. I would really like us to have demonstrator projects that show people how we can live in older age safely. One of the problems is that the HSE inherited and is the one with 20% of the provision, which very often comprises Famine-era buildings. A number of those buildings are worth a lot of money. In many ways Ireland does not know what good looks like and we need to have some of those demonstrator projects with a really good budget behind them and a world-class architecture and great design. All those ideas are there and have been worked on, and the household model has been worked on, yet it will not get support generally within the HSE. The public has to know that we actually can do these things and we need to be proud of them. That is my point.

Mr. Seán Moynihan

On hoarding, hoarding disorder is classified as a condition by mental health professionals, so it actually is a condition. It is linked to issues like depression, anxiety disorders, obsessive-compulsive disorder, OCD, and attention deficit hyperactivity disorder, ADHD, in that respect. For us, what happens with hoarding is that, obviously, people need the physical support to deal with the problem, but they also need the psychological support because without that, they will feel bereft. There is the idea that one would go into a house and clear it without the resident being involved and supported. It is another area because it is a mental health disorder in respect of which, ultimately, there needs to be planning, funding and understanding. Local authorities at one stage used to help out with the odd skip or this or that. That type of thing has stopped now, yet a lot of this is discovered when people go into hospital because then, in trying to get a discharge plan, it is suddenly discovered that there are no social supports.

The housing conditions can involve environmental health, etc. Building a little on Mr. Taylor's point on that, around 20% of what we deal with are housing issues. People may not know that. Obviously, one conversation happening in this country is about the housing needs of younger people, and we all want everybody to have a home and the safety and security that goes with a home, but the reality is that older people also have huge housing challenges at the moment. These include houses that are no longer fit for purpose for them; the ability to right-size if they want that; alternatives to nursing homes; and safety and security in private-rental or long-term leases. The fact is that the State needs to provide those houses because housing in old age is about safety and security.

On loneliness, the second question, the understanding or definition of loneliness we use, from talking to clinical experts, is an unpleasant feeling we get when dissatisfied with the quantity and quality of our social relationships and everything that spins out of that, which we have previously discussed. Some of that happens for older people from the fractures of life, for example, retirement, bereavement or poor health. All of those are things where support structures disappear and people's mental health and resilience are threatened, yet we do not go in to provide support.

Around cocooning, the-----

Deputy John Lahart

Before Mr. Moynihan continues, will he give us that definition again?

Mr. Seán Moynihan

The definition we use is that loneliness is an unpleasant feeling we get when dissatisfied with the quantity and-or quality of our social relationships.

An Cathaoirleach

Will Deputy Lahart agree to let Deputy Hourigan in at this point as she has to leave at 12.30 p.m.?

Deputy John Lahart

That is fine. I have finished.

Deputy Neasa Hourigan

I thank Deputy Lahart and the Cathaoirleach. The hoarding issue is very interesting. I have a friend in the UK who is from an architecture background and now works with people who engage in hoarding. One of the issues we talk about often is that councils in the UK have started to set up specialised units to deal with this issue. Hoarding is a growing disease because we all own more stuff now than we did in the past and hoarding behaviour often links into trauma and how it presents. Councils in the UK have these specialised units and are starting to take the issue very seriously. Is this something we should be looking at in Ireland?

Mr. Seán Moynihan

In fairness, that is the direction of travel. We need to combine the environmental health functions and services of local authorities with the emotional and mental health supports needed to cope with this issue. As the Deputy said, it is a growing problem that is usually discovered when it has reached crisis point.

Deputy Neasa Hourigan

It is also one that does immense damage to buildings. Councils, as planning authorities, have a vested interest in ensuring people are supported through it.

Mr. Seán Moynihan

I agree. They also have a vested interest in that environmental health issues may come into play in such situations.

Deputy Neasa Hourigan

Absolutely.

Mr. Seán Moynihan

In Ireland, there is a policy from 2019, I think, on health and housing. We need a lot more of that type of policy because there is an interplay between the two relevant Departments that is vital to people who are ageing in the community.

Deputy Neasa Hourigan

I have questions on funding. Were the witnesses surprised to find there is not a huge amount on the needs of older people in the implementation plan for Sharing the Vision for 2022 to 2024? In preparation for this meeting, I looked through the plan and could not find any mention of loneliness. Is it a major stumbling block when it comes to the drawing up of annual budgets if these issues are not written into documents like that? Does it lead to an uphill battle when it comes to securing funding?

Ms Róisín Clarke

Older persons' mental health is conspicuous by being almost absent in that document. Going back to my earlier point, we are seriously falling short in this area. We have the essence and the approach correct in terms of how we want to develop mental health services, which is based on the life cycle approach and with integrated care being couched into all HSE approaches and all of our national legislation. However, we are missing the piece about older persons. With an ageing population, we cannot afford to continue in this vein. The failure to address this issue is a massive deficit. Older people are not adequately represented in Sharing the Vision.

Deputy Neasa Hourigan

The issue is mentioned twice in the 136 pages of the implementation plan.

Ms Róisín Clarke

Yes, in 100 recommendations. It is very much absent.

Deputy Neasa Hourigan

I have a follow-up question. Ms Clarke referred to the need for an integration of services, which is something that applies across a number of sectors, not just for older people but right across mental health provision. Any group or cohort needs an integrated service. We see it in disability services, where there is the involvement of families and so on. Time and again, when I ask why a programme has not been done or who to ask about following up on something, I am directed back to the HSE as the core and primary source as to why a particular amount of money is or is not being spent or how it is being spent. When it comes to a full integration of services for older people, it is not just about health. We have discussed housing and I might talk about day centres presently. Is this kind of centralisation of funding, whereby every question on mental health provision goes back to the HSE, useful for integration? Is it possible, say, that some funding could come through Pobal or community groups in a more dispersed way? Is the centralisation of funding resources for mental health through the HSE working for us?

Ms Róisín Clarke

If we are talking about really working outside of silos and collaboration and interagency work, it then follows that the funding would be of a similar framework, that it would be more diverse and focus on community, healthcare and mental health.

Mr. Mervyn Taylor

I made a point in my opening statement about the new regional health authorities, which are in many ways just-----

Deputy Neasa Hourigan

I am well aware. I am sure Mr. Taylor has a lot to say about them.

Mr. Mervyn Taylor

-----six new health boards. It is a reorganisation of the HSE but there is an opportunity for integrating acute and community services and, within that, I hope, mental health, within the HSE. Where are the GPs and pharmacies, the citizens groups and the self-help, mental health and independent advocacy groups? They are somewhere in the corner of the PowerPoint slide, to put it politely. That is a problem. When established, each of the regional health authorities will have a CEO who will report to a CEO, Mr. Bernard Gloster. Currently, there is no structure in which people can ask this question of the regional health authority in which they live. That is one of the democratic deficits. I do not mean everybody is going to vote as to whether there is going to be a knee surgeon in Ardee; that is not the issue.

Deputy Neasa Hourigan

When there was a devolved version before, for example, the mid-western health board, councillors went to the board's meetings and could ask specific questions. There was, therefore, a democratic role.

Mr. Mervyn Taylor

Precisely. I fully understand that the regional health authorities need to be phased in over a period of time. That is acceptable and the HSE needs time to devolve. I express concern regarding the services, if you like, civic society and the organisations we represent. Regarding the social initiative which identifies issues that can mobilise people and get public money from the State, those institutions and organisations must be knitted in and there must be some structure for them to influence the service. Otherwise, it will always go back to the same thing. I made another point about skills. The skills are not available for the social innovation required. For example, many public health nurses need support in trying to identify how to keep somebody out of a nursing home, as opposed to the easy option, which is-----

Deputy Neasa Hourigan

To put them into one.

Mr. Mervyn Taylor

The funding is available. It takes great effort on the part of that public servant to go against the grain of the hierarchy, even if the top of the hierarchy totally supports him or her. There must be new ways of developing our public services and thinking of them more as services for the public rather than traditional public services.

Mr. Seán Moynihan

On the integration of services, to take some positives, we welcome the likes of enhanced community care,. in which there is an assessment to move more services in the community. In that area, we probably need to ensure it is given the time to mature. Sometimes, with these things, we set them up and then ten minutes later, if the trolley count does not go down, we go back to the way things were. We need time in that area.

We work closely with the Alliance of Age Sector NGOs, a group of around seven or eight other national age charities. We have also been examining a commissioner for older people, like an ombudsman for older people. Perhaps part of the committee's report could consider that. We have all outlined that while there is an awful of policy and strategy and very intelligent people have produced research and reports to show us the pathways, sometimes it is hard to hold us accountable and hold a Government or Departments accountable to move forward. That has been quite successful in Northern Ireland, for example. We can learn from our close neighbours in that regard.

We have one final point on integration. The way we think about it is in the case of somebody who needs home care support. We work with the Home Care Coalition, which is 23 agencies across the life course. If you need support to age at home, does your age really matter? That is the reality. If you have a housing need, does your age really matter? If you have a financial need, this is the reality. Here today, on behalf of the wider age sector, we are trying to get an equality of approach across the whole. We sometimes look at old people through a lens whereby we may leave them out of some of these conversations about their needs and aspirations, such as around mental health, housing and other support issues.

Deputy Neasa Hourigan

My final point is about my experience in my community. I want to talk a little about day centres, the support for day centres and how integral they are. During Covid-19, they all closed. At a time before the election, I was volunteering and we were very aware that they were open for five days a week. Then, all of a sudden, they were shut. For many people, it was their only social point.

I have a couple of questions about day centres, the first of which is on funding, which seems to me to always be slightly piecemeal. One is always worried about whether one will or will not get a grant. I have been involved in conversations in my community about whether they will get a grant. Also, they seem like an incredibly valuable framework. We have a very valuable system and other countries do not seem to have it. Many of them, though, are attached to the church and are therefore on land or in buildings that we do not necessarily have full, public ownership of. Often, honestly, the church has done a very good job in holding onto some of those services. How important are those kinds of services to communities? I am biased and I view them as quite vital for some people. They are also quite vulnerable in some ways. We are starting to see with some services that somebody is saying that a building is not fit for purpose but really, that is not necessarily actually what is going on. Then, they become homeless. It seems like, as with lots in Ireland, we do not quite control them but we desperately need them and we do not want them to go. My question is about how we support them. Are we worried about those kinds of services?

Mr. Mervyn Taylor

ALONE will obviously have a view and I hope they will come in. I do not wish to be amusing about it but I do not know why we have to call them "day centres". Many people drop down to the pub, but the pub will be closed. There are an awful lot more pubs being closed. These are the centre of the community in a way that people do not actually appreciate. It is not all about alcohol binging. Seriously, they are actually day centres. They are community centres and many of them are involved in different ways. For some of them, nobody knows who exactly they are linked to, because some of them are GAA, some of them are churches and some of them are everything. I would say that a good third of the people on the committees are atheist but that does not matter. The fact of the matter is that they are there and they are being used.

I would be cautious about just saying "day centres for old people". The key thing is that we need to rethink our idea of public services. Rather than just being meals on wheels - which is important - what about getting the wheels under the people to come so they can actually socialise and so they can get linked in with citizens' information? This is the sort of support that tackles loneliness and it also allows people to realise just how resilient they are. Other generations can come in and learn from that.

We have lots of buildings but it is a question of looking for money for buildings and day centres that need to meet these criteria at a very high level. However, the world does not operate like that. Why do they have to meet some HIQA-like standard? Many older people live their lives dropping in and out of all sorts of houses that do not necessarily meet HIQA's standards, or anybody else's standards. Let us just think about the actual engagement with one another and where that can happen. That is a day centre. We just need to rethink how services and outcomes-----

Deputy Neasa Hourigan

That sounds a little more like the personal budget model in the UK.

Mr. Mervyn Taylor

Partly, but also-----

Deputy Neasa Hourigan

Is there a danger there, though, that we might lose some of those services because people will choose to go to the pub?

Mr. Mervyn Taylor

Yes.

Deputy Neasa Hourigan

The funding would not be there, then.

Mr. Mervyn Taylor

Can I just make the point that we need to fund?

There are day centres there which are operational and do very good work but let us also look at a more innovative approach. There are facilities there like music at night and the afternoons and people can teach classes; we just need to reimagine some of the public spaces that we already have.

Deputy Neasa Hourigan

And allow the funding to follow that.

Mr. Mervyn Taylor

Yes, exactly.

Deputy Neasa Hourigan

That is the tricky bit, though.

Mr. Mervyn Taylor

That is the tricky bit because – and this is the problem of all public funding – it does not come from our department and is narrowly focused. We do not focus on outcomes. We funded a major piece of research some years ago with the late Trutz Haase and Dr. Kieran McKeown and we put forward a completely new view of how supports and services for older people could be looked at through social enterprise and I still believe in that approach. We actually need to use money in a more enterprising way. Businesses will benefit, older people will benefit and in the process, we will develop a new way of providing public services.

Mr. Seán Moynihan

For us, day centres are part of the infrastructure and the choice for older people to create places where we can have social connection. At one stage we were in discussions where in one part of the country, the HSE was asking us to take over five different day centres. It is not our area of expertise and we discovered that they were all run very differently and not on the basis of a programme. There can be a situation where older people create the connection and create and drive some of their own activities. At the same time, for mental health, we can identify people who may have loneliness or social anxiety and we can intervene. For those who may have lost physical capacity, we can run the type of social and physical activities to keep people helped and well. We understand the HSE has a plan to try to reopen 95% of centres this year. We realise several are closed because of building works and Covid protocols. We would like to see them all reopen but we would also like to see ongoing commitment to them and ongoing development of what they can actually do because it creates an engagement where we can do so much more than a situation where people just pop down for a few hours. We can meet multiple needs and really get into prevention, especially around mental health.

My colleague from Sage, Mr. Taylor, spoke about funding things slightly differently. Things such as social enterprise are an interesting concept that should be explored and expanded more. It could be the housing with support that we talked about earlier which could be run as a social enterprise. It would also mean that older people feel they are entitled to a service rather than relying on an NGO. We use NGO rather than charity because we do not want any older person to feel that with all the contribution they have given to the community, that just because they ended up in loneliness or poor housing or financial conditions that they are relying on charity. We very much like to see ourselves as a service and we think that is the kind of philosophy that social enterprise promotes.

An Cathaoirleach

I have some questions. My first is for Mr. Taylor. Is he aware of what the delay is with the Law Reform Commission report on adult safeguarding? Has there been an update or has he heard anything?

Mr. Mervyn Taylor

I do not think I am in a position to answer. I would have originally expected it last summer. I think we may see it within this year but any influence that this sub-committee or the main committee can bring to bear on that would be important. It will be a significant report because, we understand, it will put forward a legislative framework.

It will have an impact on every organisation from the HSE to the Central Bank. That is quite a span. It is not that every older person needs safeguarding – far from it – but it is a way of focusing attention and resources on those who do. It will have important implications. At the moment, it is very hard to share information because of GDPR, but some information needs to be shared and the law is a little unclear. In this regard, we have asked the Data Protection Commission to clarify and give guidelines on sharing information related to vulnerable people. We are now seeing a cohort of sexual predators in congregated care and encountering issues such as people exhibiting sexually predatory behaviour arising out of dementia, but we have great difficulty in getting anybody within the system to address these issues. They really are issues.

Safeguarding provides an overall mechanism to achieve a route forward but there has to be a national adult safeguarding authority. The safeguarding teams have to be independent of the HSE. A couple of years ago, during the Covid pandemic, there was an appalling case where a client of a nursing home died in a hospital with maggots in a wound. A report on that is due. I will not go into the details but one of the issues that came up was that because the person is in a private nursing home, the HSE safeguarding teams say they have no legal authority to go into it; yet the HSE is administering the very nursing homes support scheme that keeps the person in that home. These are examples of how our public funding and policy are not joined up.

The safeguarding legislation is vital because it will be a framework across financial services, social services and, indeed, some educational services. I am aware that the Cathaoirleach is interested in this. Former Senator Colette Kelleher first put it forward in 2017. There was all-party support for it at the time. What will come forward from the Labour Relations Commission will be a framework that we hope will be almost oven-ready for the Oireachtas to debate and move forward fairly quickly into legislation.

An Cathaoirleach

It will be interesting to see when the report will come out. Mr. Taylor believes it will be out this year.

Mr. Mervyn Taylor

My hope is that it will be out this year. At this stage, we must ask what the delay is and whether it is the lack of resources or something like that. Where there are turf issues and the HSE safeguarding teams cannot or feel they do not have the power to go into a private nursing home, it is absolutely appalling.

An Cathaoirleach

I thank Mr. Taylor. Mr. Moynihan mentioned loneliness earlier. He wanted to know whether there was somebody he could talk to who could deal with loneliness in general. Could he say a little more about what he meant?

Mr. Seán Moynihan

Loneliness is obviously a complex issue across all age groups. The reality is that it will require a range of psychosocial responses from health professionals, but also community groups, and also social activities, etc. We realise, from all the research, that this is an issue. In fairness to the HSE, the Department of Health and the relevant Ministers, people realise this is an issue that needs to be addressed.

We seem to get a little stuck there. We realise we have the evidence, but where do we go from there? For its part, ALONE recognises that the CMO recently came out with an open letter on loneliness and that this is a really positive move, as is the advertising, but it did not really discuss the language we need to destigmatise loneliness. For the older people who come to us for services around loneliness, imagine making that phone call and admitting that you are lonely. That is a really brave thing to do. As a result, a bit like what we have done with younger people's services, we really need to educate and work with older people and create the points at which they can reach out. A publicity campaign has been done to tell people to watch our for loneliness and to re-engage, but, really, we need a strategy and a plan that covers all age groups and reaches in further.

An Cathaoirleach

How would ALONE see that plan or strategy? Is there a model-----

Mr. Seán Moynihan

As usual, in different parts of the world there are different elements whereby people have taken on this challenge. At one stage, the authorities in England launched a loneliness strategy. The authorities in New Zealand have launched one as well. There are places to learn from and policies to go on. There is great knowledge within the system of the negative effects of loneliness and great research out there. We now need to move into implementation and creation of a plan to respond.

An Cathaoirleach

Does Ms Clarke want to come in?

Ms Róisín Clarke

On the point of loneliness and potential strategies that could be used to address it, there are a number of mentions in Sharing the Vision of social prescribing and its benefits for mental health. Again, however, it goes only so far and the older person is that missing piece of the jigsaw puzzle. As I understand it, and it would be good to know more about what stage it is at, there is a framework in place for social prescribing and delivery in the communities around Ireland. Potentially, therefore, if we could link in what is out there, what has been established and what we can potentially leverage and then draw a focus in its place with older persons' services within the community, there could be some benefit in that.

An Cathaoirleach

We are about to see the enactment of the Assisted Decision-Making (Capacity) Act and the decision support service, which should see us move from a substantial decision-making approach to a more person-centred and human rights-compliant model of decision-making. This is a really positive development - I am sure the witnesses would agree - but how can we make sure that older people are empowered in this new system to make the most of this progressive change, and can the witnesses see the link?

Mr. Mervyn Taylor

Yes, absolutely, if it is an opportunity to shamelessly plug something we have just done.

An Cathaoirleach

Great.

Mr. Mervyn Taylor

On our website, sageadvocacy.ie, you will see a short video on the legislation called Minding Your Marbles. The legislation is among the most complex around. The consolidated Acts of 2015 and 2022 are an inch thick, but we took them down to a simple phrase. It is a colloquial phrase around Ireland. Many older people, when they forget something or are worried about their memory, say, "I must be losing my marbles." We took that phrase and decided to build the awareness around this issue because "minding your marbles" is the phrase people use. We have to realise that the legislation we are still under until Wednesday of next week dates from the year after the death of Charles Dickens. I refer to the Lunacy Regulation (Ireland) Act, 1871, and the system of wards of court relating to it. We know that all the ward of court cases will be reviewed.

There will also be people coming forward who will lack capacity. The courts - the Circuit Court rather than the High Court - will be looking at those cases and, where appropriate, appointing decision-making representatives. There are greater safeguards under that but it also needs the protection of liberty legislation and the safeguarding legislation. It is a profoundly important piece.

There is a development in relation to advance healthcare directives. They already have informal legal support. They are now formally recognised. That is one way older people can protect themselves, by appointing a designated healthcare representative. The second way is enduring power of attorney. There are very low levels of uptake of enduring power of attorney. I am one of them; I am considering it at present. However, it is not something that one would rush into. There are issues of cost. We are pleased to see the Legal Aid Board seems to be taking that on board in its planning for the future. Advance healthcare directives, the enduring power of attorney and a very good resource which was developed by the Irish Hospice Foundation or the Hospice Friendly Hospitals, Think Ahead, are the kinds of resources we need to propagate so that people can get used to the idea that if they are in difficulty in controlling the decision-making process or if they lose the ability, either temporarily or permanently, they are still speaking and their wishes or, as it is known, will and preference can be taken into account.

Much more will have to be done. The legislation is a brilliant start. It is 20 years since the Law Reform Commission first started talking about the need for the legislation. I remember sitting in the Dáil Visitors Gallery in December 2015, which is a while ago, when the first main Act was passed. It is coming into effect next week. It is now about getting the support behind those mechanisms and encouraging people. For example, when people get their social welfare payments, there might be even little messages with which one might encourage them.

Advance healthcare directives, enduring powers of attorney, EPAs, etc., are making it much easier for people to mind their marbles. Coming back to that simple phrase, it is really important people engage with the fact they might even have a stroke in their 40s or some other illness in their 50s and that they need to have their will and preference known and somebody else to be able to speak for them, which we do often for people. It would be an awful lot easier if we had those instruments widely and cheaply available.

Mr. Seán Moynihan

We recommend the widespread implementation of this. Moving to a situation where we assume people have capacity over their lives is to be welcomed. Ultimately, part of this legislation is to give voice to people's will and preference.

As Mr. Taylor said, in fairness to the Oireachtas, the Act was passed in 2015. It has been a long journey to get here. In some ways, on an everyday basis, in those eight years and prior to that we saw some of the biases, especially in the case of older people who might have had or have mental health difficulties. Ultimately, there was that assumption that they do not have capacity. Every day older people dealing with health services and other challenges in their lives face a situation where people discuss or look to discuss the issues with those people's sons or daughters rather than directing the discussion to the individual in person. We are hoping that, through the enactment of this legislation, the training and development and the wider understanding of that, there will be a spin-off in regard to those everyday ageist practices that happen in multiple agencies.

We hope people will realise it is about older persons, their will and preferences, and that we must assume they have the capacity and ability to make these decisions for themselves, albeit sometimes, when required, with elements of support.

An Cathaoirleach

Is there a specific organisation to which older people can go if they feel lonely or that they have particular mental health issues? ALONE probably performs some of that function as part of its work. However, is there a stand-alone organisation that deals specifically with mental health issues in older people and, if not, is such an organisation needed?

Mr. Seán Moynihan

As referenced in our submission, this is a conversation that needs to be had. Excellent organisations like Jigsaw exist for younger people, which has helped to move on the whole debate, the quality of services and supports provided and the whole understanding for younger people of how important their mental health is. The TILDA research shows that 15% of older people are facing mental health challenges. Older people now make up close to 20% of the population. All they are looking for is that the resources, care, supports and opportunities available to young people are also available to them.

Ms Róisín Clarke

To the best of my knowledge, there is no specific stand-alone organisation dealing with mental health issues in older people.

An Cathaoirleach

It would be fantastic to have such an organisation.

Ms Róisín Clarke

Absolutely. As Mr. Moynihan said, by virtue of the numbers alone, a champion certainly is needed for older persons in respect of mental health services provision.

Mr. Mervyn Taylor

Sage Advocacy is an independent advocacy service for older people. There is a real need for skilled, independent advocacy services for people with mental health issues. It is a complex and very challenging area. Such a service just does not exist at the moment, both for the provision of peer advocacy, which is not always suitable, and representative advocacy. This is something the sub-committee might consider. There is a strong message in my submission that such a service is needed. When people become lost in the system for whatever reason, independent advocacy is often the bit that binds the pieces together and helps them to get out of the ditch, so to speak.

Ms Gráinne Loughran

There is a range of organisations, including Aware and Samaritans Ireland, that work with mental health issues more broadly. Samaritans released research this month showing that self-harm, which it looked at across the whole life course, is not just a young persons' issue and can persist throughout a lifetime. One participant had been engaging in self-harm for more than 50 years. There also are organisations like Bodywhys, for example, which deals with people with eating disorders. It has noted that clinically disordered eating can continue into older age and, in fact, that its duration may be longer in older adults than in younger people.

Many of these organisations are focused on issues generally across people's life course. As we mentioned, there are different symptoms of some mental health difficulties in older age and there is sometimes less focus on this. We are historically on the back foot on a range of aspects of mental health provision. For instance, the expert group that put together A Vision for Change in 2006 did not have input from psychiatry of older age teams. We are on the back foot across a range of areas and this is just one of them.

An Cathaoirleach

This has been a fascinating discussion. I thank the witnesses most sincerely for their attendance. Although we were aware of the issues, this engagement has opened our eyes a lot more. I compliment the witnesses on the great work they all are doing. It is phenomenal and we in the sub-committee sincerely thank them for it.

I want to thank the representatives of ALONE and Sage Advocacy for assisting the sub-committee in its consideration of this very important matter of the life cycle approach to mental health, particularly in the context of older people. I will now adjourn this meeting sine die.

The sub-committee adjourned at 12.55 p.m. until 11 a.m. on Tuesday, 9 May 2023.