Seanad Éireann díospóireacht -
Thursday, 21 May 1981

Vol. 95 No. 19

Health (Mental Services) Bill, 1980: Second Stage.

Question proposed: "That the Bill be now read a Second Time".

Minister for Health (Dr. Woods)

This Bill is the first comprehensive piece of legislation concerned with the treatment of mental illness to come before the Oireachtas since the enactment of the Mental Treatment Act of 1945. Before 1945 the treatment of mental illness had not been the subject of legislation since the heyday of Victorian mental hospital building. From this chronology it might appear that legislation makes only sporadic and widely-separated forays into an area which raises many serious questions of importance to doctors and lawyers and which has effects on one of the most vulnerable sections of society. In a sense this is true and reflects a more widespread reluctance among the public to interest themselves in the whole area of mental illness and its treatment. On the other hand the years in this century in which legislation has been passed, 1945 and 1981, mark fairly obvious milestones in changes in attitudes to mental illness.

Nineteenth century legislation was enacted in an era which saw no hope or future for those diagnosed as suffering from mental disorders, and created large institutions, often in isolated parts of the country, to contain and separate those whose behaviour would not be tolerated or understood: little distinction was made between those who were considered lunatics and those who committed criminal offences. They were both dealt with by similar judicial procedures and consigned to almost identical institutions. The similarity in architecture between some of our older mental hospitals and prisons constructed at the same time is striking.

By 1945 attitudes to mental illness had changed considerably. The origins and causes of mental illness were better understood and consequently modes of treatment became available which, though they may not have effected cures in the strict medical sense, did at least help people to manage the symptoms of their conditions and so helped gain acceptance for the notion of mental "illness". These mental hospitals replaced lunatic asylums and, for the purpose of committals, judicial procedures were replaced by medical certification. This was the major advance made in the Mental Treatment Act of 1945.

During the entire span of human activity enormous changes have occurred since 1945 and so it is only proper that the legislation dealing with mental illness should be re-examined in the light of contemporary needs and attitudes. This is not to suggest, of course, that no legislative changes or changes in the organisation of services for the mentally ill have occurred in the past 36 years. The Mental Treatment Act of 1945 was amended in 1953 and again in 1961. The Report of the Commission on Mental Illness was published in 1966. Many of its recommendations which did not require legislation have since been implemented.

The Health Act of 1970 which radically altered the pattern of delivery of health services also affected the mental health services. That Act obliged health boards to provide in-patient and out-patient services for patients suffering from mental disability — a point missed by some critics of the Bill. Therefore, in the light of the number of amendments which had already been made to the 1945 Act, and the general re-organisation of the health services which had occurred in the early seventies, it was felt that the Bill which is now before you was necessary to reflect the changes which had already taken place as well as providing a legislative framework flexible enough to accommodate changes likely to occur in future years. The obvious question arises now of how to construct such a framework.

The first requirement is that the Bill should reflect contemporary and likely future attitudes to those suffering from mental illness. An obvious starting point is that mental illness is indeed an "illness" much like any physical ailment. Its causes may be more complex and difficult to find, but it most obviously must have a cause and much mental illness must have a cure. These characteristics are common to all branches of medicine. Therefore, a fundamental principle of this Bill and of the mental health services is that, where possible, mental illness is treated on a similar footing to physical illness.

There are obviously some areas where special facilities and procedures may be needed, and these must be the concern of mental health legislation. In my view there is no need for special legislation to deal with the patient who voluntarily presents for treatment for some acute disorder. The Health Acts are perfectly adequate to deal with such cases, which constitute the great majority of admissions to mental hospitals. Special provision needs to be made for those who, by reason of the severity of their illness, are no longer capable of making the rational decision to seek and accept appropriate treatment. I make no apology for the fact that the bulk of this Bill is concerned with the provisions which need to be made for this category of patient.

For the purpose of discussion the Bill can be readily divided into three areas: the registration and supervision of psychiatric institutions, admission and discharge procedures and safeguards for patients.

As I have just mentioned, these are areas which are not of general concern to voluntary patients except where indicated in the Bill, and this approach has led to some misunderstanding. Some critics have claimed that the Bill does nothing for the voluntary patient, and that it does not make provision for community care services or out-patient clinics. Anyone familiar with health legislation knows that there is provision for all of these categories of patient and service in existing health legislation.

In dealing with the three main areas of the Bill as I have outlined them I will indicate where major amendments were made to the Bill in its course through the Dáil. As I have said before, I welcome comments and suggestions as to how the Bill might be improved.

In dealing with the registration and supervision of psychiatric centres the Bill aims to simplify the existing categories of institutions. In future there will be only two basic types of psychiatric hospital, district psychiatric centres run by health boards and registered psychiatric centres run by private individuals or organisations. These centres will provide treatment and care for the overwhelming majority of psychiatric patients. A third minor category are registered psychiatric homes which would provide convalescent home care. There is only one such home at present.

In basing the services on psychiatric centres I do not mean to imply that hospital care is the only treatment for mental illness. I regard the modern psychiatric hospital or unit as a resource centre which provides in-patient care as only one element of a total service.

The hospital also services out-patient clinics, day hospitals and hostels. It is also the base for the community psychiatric nursing service. Of course hospitalisation will be needed for some patients, even if only for a short period. However the objective is to keep this period to a minimum and to return the patient to a full life in the community where treatment can be continued if necessary.

In dealing with admission and discharge procedures the Bill simplifies matters by proposing to have only one category of detained patient. In this context I should point out that the Bill abolishes the existing category of a person of unsound mind, who was subject to indefinite detention. However the major change is the requirement that two medical practitioners should sign a recommendation for reception before a person is detained in a psychiatric centre. This change has aroused some controversy, though I should point out that such a requirement already exists for private patients. It has been argued that there are areas of the country where it might be difficult to get two doctors in an emergency. To allay such fears I introduced an amendment in the Dáil which allows the Minister to designate geographical areas or circumstances in which the signature of one doctor will suffice. I hope that such areas do not exist and that such circumstances will not arise, as I believe that the two-doctor requirement is a reasonable one where nothing less than the deprivation of an individual's liberty is at stake. I could not consider the insertion of a more general emergency procedure as I believe that where such procedures are available they rapidly become the norm. Experience elsewhere provides ample evidence of this tendency.

As I mentioned earlier, these procedures apply only to those who need to be detained. They do not affect voluntary patients seeking treatment of their own accord.

Section 19, subsection (5) (vi) requires that the doctor who signs a recommendation for reception must each certify:

(i) that the person is suffering from mental disorder of such a degree that detention and treatment in a psychiatric centre are necessary in the interest of the person's health or safety of the protection of other persons or property, and

(ii) that the person is not prepared to accept or is not suitable for treatment otherwise than as a detained patient.

These criteria are as amended in the Dáil. In the course of the consultation process which I initiated on the Bill's circulation I was advised that this formulation of the criteria for detention is more in keeping with the contemporary terminology of psychiatry.

There is one point to which I must make special reference. I was, reluctantly I must say, persuaded to make one change in the area of the voluntary patient, and that was to agree under extreme pressure in the Dáil and by the medical profession to require that such a patient give 24 hours notice of his or her intention to leave hospital. I was persuaded primarily on the grounds that it was necessary in the interests of a small number of cases to do so. Deputy Browne took issue with me for doing so, and I found the amendment difficult to defend since it represented a marking out of a difference between the person undergoing treatment voluntarily for psychiatric illness and a person undergoing treatment for any other illness. This part of the Bill also makes considerable improvements to the whole area of patients' rights. New procedures are introduced to inform patients of what is happening at each step in the detention process and of their rights under the Bill.

The fear of indefinite detention in a mental hospital is almost certainly one of the main reasons for a certain reserve which attaches to the psychiatric service. To allay this fear and so, we hope, to remove any remaining concern on this point the Bill has a number of provisions establishing review procedures for all detained patients. The most significant change is the establishment of review boards to which a detained patient or other categories of persons designated by section 38 can apply for an independent review of the need for continued detention. These boards will consist of one consultant psychiatrist, one legal practitioner and a third person who is not a member of the medical or legal professions. Each health board area will be served by one or more review board or boards. This is a most significant development, which has been widely welcomed by those interested in the care of the mentally ill.

Some elements in the medical profession have been concerned that the consultant psychiatrist's advice might be ignored or over-ruled by the other two members of the review board. As I said during Second Stage debate in the Dáil, this seems to me to postulate a very abstract and unreal situation. I cannot seriously believe that highly qualified psychiatrists would not be able to articulate their opposition to the discharge of a patient in a manner which would convince their non-medical colleagues.

In practice, of course, the non-medical members of the board will have the fullest regard for the professional opinion of their medical colleague and also to the opinion of the medical consultant in the psychiatric centre where the patient is detained.

There has been, I might say, a criticism of the absence of definition of treatment. It is in my view impossible to provide a meaningful legislative definition of treatment. In any case such a provision would serve little purpose. Programmes of treatment now encompass not only the application of medical treatment and nursing care but increasingly demand the establishment and development of a very high degree of personal integration between staff and patients. Patient activation has become a major element in the treatment of mental illness—occupational and industrial therapies, workshop activity, social intergration and so on. Because treatment is not defined in this Bill does not mean treatment is not provided. Of the patients discharged from psychiatric hospitals 90 per cent have been there for less than three months and in 1978, total discharges came to 26,684 as opposed to a total admissions figure of 27,662. These figures reflect a high level of treatment activity. Further, despite a trebling of the number of annual admissions to psychiatric hospitals during the last 20 years, the public hospital in-patient population has fallen by about one-third over this period, that is from 19,400 patients in 1960 to 12,500 patients in public hospitals at present.

A feature of the hospital service provided for psychiatrically-ill persons is that provided by acute units associated with general hospitals. There are 400 such beds and a further 500 such beds are being built or are in planning. Even more significant are the developments which have taken place in the provision of informal treatment in the community setting. Day centres and the provision of treatment at home are both areas which can prevent unnecessary hospitalisation in the first place, while an increasing use of residential hostels to provide intermediate and after-care services for discharged patients can serve to provide rehabilitative care and thus minimise readmissions.

In 1977, there were 30 supervised hostels within a community setting, providing care for some 300 patients. There are now 600 patients cared for in more than 60 such hostels. Community psychiatric services are provided by 200 psychiatric out-patient clinics and by 150 community psychiatric nurses at which there are annually now more than 180,000 attendances by 36,000 patients.

It has been suggested by a number of critics that I should specify in the legislation minimum standards of care for mentally-ill patients. Such a proposition raises interesting questions. Can one, for example, set down minimum standards of professionalism and dedication on the part of medical nursing and other personnel caring for patients? Professionalism and dedication are, of course, essential not merely in ensuring the efficacy of treatment and in securing the necessary degree of individual attention for patients but also in developing a humane and caring environment within the hospital setting. However, it has never been made clear how professionalism and dedication could in practice be regulated and then "policed". Such a system would totally undermine the self-confidence of staff, assuming as it would a lack of basic competence on their part. Such a system would also necessitate a constant intrusion by central authority into the day-to-day operation of psychiatric hospitals, thus robbing staff of their basic authority and independence. This draconian situation would be a logical outcome of any attempt to define in law a concept as nebulous as that of "adequate treatment" for the mentally ill.

The question of minimum standards of mental health care would include matters such as accommodation, patient dignity and privacy and so on. The general question of the feasibility of providing for minimum standards in these tangible areas is at present under consideration in association with the Irish Medical Association. I am strongly of the opinion that any meaningful standards of mental health care would also have to encompass closely related questions such as activation programmes for patients, and the degree to which staff-patient integration contributes to simulating normal life settings. These are complex topics which cannot be provided for in legislation, but which might be catered for by general "guidelines".

In concluding may I ask Senators to approach the legislation in the spirit in which it has been introduced, namely, that of bringing the custodial element of the psychiatric service into line with the requirements of the late twentieth century to protect the best interests of those who need to be detained for treatment? The provision in section 13 of the Bill that nothing in the admission and discharge procedures should be seen as discouraging a person from being admitted voluntarily for care and treatment is intended to emphasise the fact that for more than 90 per cent of patients requiring to go to hospital for treatment for psychiatric illness there is essentially no difference between them and anybody entering hospital for treatment for a physical ailment.

Mr. Cooney

I suspect that the Minister is a little disappointed at the reception which has been given to this Bill in the other House and also by interested parties. The Minister possibly expected that, because this was the first major piece of legislation in this field since 1945, there would have been a greater welcome for it and possibly a recognition that it was a significant measure. Part of the reason for the low key reception of the Bill is that it is to some extent an anti-climax when one considers the expectations that were raised for legislation and reform in this area by the manifesto of 1977. There was an undertaking in that manifesto for a complete reorganisation of the mental health service and for a comprehensive national programme for the mentally handicapped.

When we look at this Bill in the light of those undertakings we have every reason to be grievously disappointed. Regarding the first undertaking — to undertake a complete reorganisation of the mental health service — I do not think anyone could argue in even the slightest degree that this Bill fulfils that undertaking. As the Minister has said, the Bill is a comparatively narrow Bill in so far as what it deals with is the law concerning the minority of mental illness cases, those who have to be compulsorily admitted to hospital and compulsorily treated. That is the essence of what the Bill is about and the vast majority of the sections in the Bill deal with that particular part of the problem. As I say, the patients in that category are a very small minority of the total. I do not think that a Bill dealing with their admission and discharge and providing for the registration and supervision of psychiatric institutions can be called a Bill that provides for a complete reorganisation of the mental health service.

I take the Minister's point that professionalism is not something that can be legislated for. This is something that comes from the level of training and the personal commitment of the professionals concerned, and I sympathise with him in having to sustain that particular criticism. I do not think there is a need for him to be as defensive about it as he was in his opening speech here. One can sympathise, too, with the critics who argue for the highest degree of professionalism and the highest levels of care to deal with all ill people, but it is a mistaken notion to think that an Act of Parliament can lay down the level of care. That is something that comes from the training and the commitment primarily of the people involved, but it is something that also depends on a third factor, and here the Minister could have a role to play. That third factor is the infrastructure — we will call it that — that the State provides for these people to exercise their professional role. I recall when moving changes in the adoption law that there was considerable pressure for the introduction of standards in the adoption law concerning the level of expertise in adoption work, and, like the Minister, I had to point out that an Act of Parliament cannot provide for specific levels of expertise. That is a matter for the persons concerned, their dedication, commitment, professional skill and training, though one can provide the general context in which these people operate so as to provide the optimum context so that their services can be best availed of and can be most effectively implemented. Again the Bill is not very encouraging from that point of view.

The Minister in his concluding remarks spoke of the improvements that might be made in that area when he spoke of providing for more sophisticated therapy units and so on. Again, I find the Bill is a bit depressing in that there is no indication by the Minister of a clear longterm policy for providing this enhanced and improved physical infrastructure for the mental health services. It is referred to, but I suppose one cannot blame the Minister for being reticent about this because the money that would be involved would be substantial and the Minister, having regard to the promises that he has made in recent tours of the country for the expenditure of many thousands of millions in medical institutions of one kind or another, would really pass the credibility gap if he were to come in here and talk about the further millions that would be necessary to do what would need to be done to fulfil the manifesto undertaking of a complete re-organisation of the mental health service. The Minister is caught in his scene by the profligate misuse of the nation's resources during the past four years to the extent that the Exchequer is now in a penurious condition and is incapable of providing any of the services that the people need and are entitled to. However, that did not prevent the Minister doing a tour of the west, the southwest and the midlands in recent times and making the most extravagant promises of his intention to spend enormous and huge sums of money. That commitment, if commitment is a proper word for that sort of exercise, is such that if he were to come here and say that the health services are now going to be reorganised in order to fulfil the Fianna Fáil manifesto his credibility would take a final plunge into oblivion.

The other aspect of the manifesto in relation to mental health was to undertake a comprehensive national programme for the mentally handicapped. Unfortunately there is not a single word in this Bill dealing with the mentally handicapped. In particular the omission in regard to the adult mentally handicapped is a serious one. Mentally handicapped children are catered for reasonably well at this stage. There has been a growth in the past couple of decades of residential and day-care centres for the treatment of mentally handicapped children and there has been a considerable advance in community recognition of that problem and of community involvement in the care and treatment of it. Most communities now have voluntary associations who do an immense amount of good work, and it is right that we should pay tribute to the people involved in those associations for the good work they have done. This necessitates being personally involved as volunteers and assisting the professionals in the institutions. It also involves what is possibly the most difficult and distasteful part of voluntary community work, which is the raising of funds. They have been persistent and dedicated in discharging that particular function, and they themselves will admit generally that they have found a ready and generous acceptance by the members of the community of appeals for funds.

There has been a considerable advance in recent decades in the field of the treatment of the mentally-handicapped child but, unfortunately, the mentally-handicapped adult has been neglected and the number of institutions, whether residential or day centres, available for the mentally handicapped adult is scandalously low. It is a matter of great disappointment that the Minister and his colleagues in Government four years after promising a comprehensive national programme for the mentally handicapped have now done literally nothing for the adult mentally handicapped. The adult mentally handicapped is still a patient in psychiatric hospitals, and of course they are most unsuitable places for such people. I have heard the Minister personally, and I have seen him reported as saying, and rightly saying, that there must be a realisation that the mentally handicapped adult is entitled to the same prospects for the fulfilment of his personality and the realisation of his abilities, limited though they may be, as any normal person and that the scene in which he has to be given the opportunity to achieve that fulfilment must be compatible with that aim. I would suggest to the Minister that merely to provide for the mentally handicapped the physical surroundings of a mental hospital is not the scene in which that person can fulfil himself, albeit to a limited degree but to a degree to which he is entitled to aspire. He is entitled to look to us to help him to realise that aspiration.

It is a matter of regret that in this Bill these people have been put on the long finger, I am afraid that they have been put on the long finger in the Minister's work over the past number of years. To provide for them would require a big administrative and financial effort. The financial effort is not possible for the reasons that I have already referred to, that the Exchequer has been run into the ground financially speaking and the resources that should be available to assist these weaker brethern are not there. I do not know why there has not been the administrative push to involve the community in the same way as the community has been involved in the case of the child mentally handicapped. I know the Mental Health Association of Ireland are doing good work but they need encouragement and support to expand their activities so that we might have the facilities necessary, whether they be residential or day care.

One reason why so much of the work for the adult or the mentally handicapped child is successful is that they can now be maintained in their homes. The burden of maintaining them has been eased by the provision of day care centres so that there is an ideal mix of day care and home care. That, of course, might not be as easy to arrange in the case of the adult mentally handicapped because it is obviously a different problem to deal with an adult than to deal with a child. We do not know how far we can go in that area. So far as I am aware experimentation and development work has been regrettably small and light.

The fact that the Minister has introduced this piece of legislation without touching at all on the problem of the adult mentally handicapped is a matter for grave disappointment. It is not a matter for surprise in so far as it is another promise not fulfilled, but obviously it is a matter for disappointment that in this sensitive area the promise which was made now looks a particularly cynical piece of electioneering at the expense of a handicapped section of the community. One can understand promises in the economic field not being achieved, where the policies went askew or where the finances were badly managed and targets were not achieved. One can possibly be a little cynical politically about it, but one cannot have the same sympathy for failure to meet a promise to the mentally handicapped of our community. The Minister and his colleagues must stand condemned for their failure to live up to what was a solemn undertaking given to people who had to rely on that particular undertaking and who have no political clout of their own. From that point of view the Minister's Bill is disappointing. It fails on both scores to implement the manifesto undertaking of a complete reorganisation of mental health services on the one hand and to provide a comprehensive national programme for the mentally handicapped on the other. Quite frankly, it does neither and is a failure in that regard.

So far as it goes I would not have any great objections or quibble with the detailed provision in it, with one or two exceptions. The Minister in his speech tells us that the Bill deals with three areas, the registration and supervision of psychiatric institutions, the admission and discharge procedures, and safeguards for patients. Obviously the registration and supervision of psychiatric institutions is something that is desirable and I would not take issue with what is proposed here. Provision for the designation of institutions under the health boards and for the registration of private psychiatric centres is desirable and commonsense. Such institutions should be designated and supervised. It is inevitable that there will have to be specialised hospitals for the mentally ill. As the Minister pointed out, the type of buildings we have are a hang-over from Victorian days when their lay-out, design and architectural style were unfortunately similar to custodial institutions and that reflected the thinking of those days in relation to mental illness.

In recent years there has been the beginning, and I suppose some journeying along the road towards recognition of the fact that mental illness is just another form of illness, that it is not a matter for shame, or a matter to be hidden or a matter for disgrace for the unfortunate patient or his family connections. This is something which requires a change in social attitudes. How they come about is the problem. I suppose they can come about in two ways. The medical profession and the people in the Minister's position have the obligation to preach that mental illness is another from of illness and is not something socially disreputable. That is one way in which the climate of thinking towards mentally sick people can be changed for the better.

The other way, of course, is to change the physical conditions in which they are treated. In recent years there has been a very desirable opening up of the buildings of the mental hospitals in the country. The grim perimeter walls have been taken down and there has been more mixing between the institutions and the local community. The idea of these people being in purdah and isolated from the community is being done away with. Both of those things have contributed to the growing realisation that mental illness is now just an unfortunate trauma that strikes people in much the same way as a physical illness can strike a person and that it is nothing to be ashamed of or a matter for disgrace within the family concerned. All of us have to do what we can in our own way to ensure that there is continuing development of public thought and public acceptance along those ideas.

I am sure that the Minister, through the health boards and through his registration powers, will ensure that psychiatric centres and psychiatric institutions will be designed, built, organised, managed and integrated into the community with the objective of breaking down any distinction between mental and physical illness.

The second area that the Bill deals with is with regard to the admission and discharge procedures. There are a couple of aspects with regard to this that have given rise to controversy. The first is with regard to the admission of a patient on a compulsory basis, and of course that is what we are talking about essentially in this Bill. The Minister has said we do not need law for voluntary admissions and I take his point.

There was considerable controversy in the other House and in medical circles over the requirement that for a compulsory reception there has to be a certificate from two medical practitioners. It was pointed out in the other House that this could lead to considerable difficulty in many parts of the country, not just in isolated rural areas but indeed in urban centers where medical rota systems operate, where possibly only one doctor is on call in a surgery and in some areas maybe a second doctor on duty is doing house visits. It was said that it might be difficult to get a second medical practitioner in what would almost invariably be an emergency context. It was urged on the Minister that the reception recommendation could be made by one general practitioner and that the confirmation from the second could be given after the admission of the patient to the mental institution concerned. The Minister did not accept that suggestion and he has offered a compromise by taking power to make regulations to deal with the difficulties envisaged by critics of this particular provision. I am not so sure that regulations are the answer, because regulations in this particular area would be difficult to draft to deal with the unforeseen and that is what we have to contend with. I do not know what sort of regulations or provisions the Minister has in mind to overcome the difficulties that arise because of his proposals in this regard.

He indicated that his regulations would possibly designate geographic areas where some exemption from the two doctor requirement would be given. I would make the point that if that is going to be the main criterion for the regulations applying it is mistaken, because this is a problem which can apply in the largest urban area as much as in a remote rural area. The Minister, too, was afraid that if the two doctor rule was to be avoided in cases of emergency where only one doctor was available this would become the norm, that it would be certified as a matter of course and that there would be no willingness or wish to go and get the second certification.

I do not know if that is an altogether fair or good argument. I think that if the law provides that there should be two and that if in a case of emergency there is only one available and that one suffices, we have to make some act of faith in the professional integrity of the people concerned that they would implement the law in the spirit in which it was intended as well as in the letter. I think it would be preferable to leave this problem to the medical people concerned rather than for the Minister to make regulations as to when there should be one or when they should be two people to certify a person as requiring compulsory treatment.

On the question of discharge from institutions, the Minister has said that it was with reluctance he introduced the requirement that 24 hours notice would have to be given in the case of voluntary patients. Up to now the notice required to be given by a voluntary patient before he could be discharged from hospital has been 72 hours. I gather from what the Minister says that it was his original intention not to have any length of notice at all. He did this for the commendable reason — commendable at first sight— that this person is a voluntary patient coming into hospital so why should he or she not be allowed to leave voluntarily as soon as he or she thinks fit? There is a certain logic in that if one equates that these people are all patients, but I think the logic ignores the differences between a person who is suffering from a physical ailment and a person who is suffering from a mental illness.

In the case of many mental illnesses severe medication may be required by way of tranquillising drugs and the effects of these may not have worn off within the 24-hour period. A very common case of admission to mental hospitals on a voluntary basis are alcoholics seeking admission to be dried out. People in that category can require a considerable period under tranquillising drugs before they are in a position to be treated at all. To allow them to make a decision that they are fit to be discharged in 24 hours when they are in for a course of treatment that may necessarily require longer than that is, I think, retrograde. While I have sympathy with the libertarian element in the Minister's views, I think we have to balance that with the commonsense requirement of providing services to treat these people and providing a scheme under which they can be treated. If a person goes in voluntarily for treatment I do not think it is too much for us to ask him to give 72 hours notice before he leaves so that he can get some good out of his voluntary admission.

I understand it has been the position since 1945 that 72 hours notice is necessary before a voluntary patient can discharge himself, that is discharge himself without medical consent. Of course, that is not to say that voluntary patients must all give 72 hours notice before they can go. Obviously in suitable cases a voluntary patient will be let go on ten minutes notice, but for patients who are not in a position to make an assessment about their own condition in order to be discharged or patients who have not taken the minimum of treatment for the condition for which they admitted them selves, I think they should be made subject to the 72-hour notice requirement. I am not aware of any cases since 1945 where this obligation to give 72 hours notice has been a hardship or a burden on the patients concerned. It is an admirable libertarian concept on the part of the Minister and one must sympathise with him and admire him for it but I do suggest that it is mistaken and that there is no need for it in the sense that there is no abuse needing to be rectified or remedied by it. If there was an abuse it would certainly have appeared and would be publicly known and well manifested since 1945.

It is not good enough for the Minister to change something so fundamental that inured since 1945 without being an abuse or without causing difficulty or hardship for reasons of theoretic liberalism. We have to consider the facts and realities of the real world which we are speaking about: in this case the patient suffering from mental trauma who is half-way through a course of preliminary treatment and who for some reason — obviously not a properly thought-out reason because of the very condition for which he admitted himself — decides to leave half-cured and perhaps full of drugs. The medical profession is happy that 72 hours is a reasonable time for certain preliminary treatment to be given or for certain preliminary treatments to wear off, so that it would be safe for a person to discharge himself voluntarily. When this has worked well since 1945 the Minister is making a mistake in changing it.

Another matter concerning the discharge is the review body. I would agree with the Minister that the proposed structure is a good one. There will be a psychiatrist and a lawyer, and to bring commonsense to both there will be a layman. It is a good mixture and I would not quibble with it. Some of the medical profession feel it should be an entirely medical board who should decide this matter but in view of the type of case that would be coming before it and having regard to the length of time during which that person is a patient, there should be other disciplines involved besides the purely medical discipline. You would be asking a board of entirely medical people in what is a fairly narrow profession to deal with the professional judgment of a colleague. Undoubtedly, they would bring total impartiality to their deliberations but in order to avoid any suggestions that there might be less than total impartiality, the Minister is quite right to expand this board to include non-medical people.

So far as the Bill goes there is much it to be commended but there are some points of criticism. The main point of criticism I have is the provision for the notice to be given by the voluntary patient in order to discharge himself. Twenty-four hours is inadequate, and I urge the Minister to look again at that. I would be anxious to hear from the Minister in his reply what advice he got from the medical profession regarding that particular aspect. In his opening speech dealing with this matter, it seems it was apparently as a result of pressure from the medical profession that he introduced the 24-hour notice requirement. I am anxious to know if the medical profession urged on the Minister the 72-hour notice requirement and on what grounds he decided to compromise on 24 hours when the professionals say that 24 hours notice is dangerously inadequate. I ask the Minister to spell out for the House the reason he is satisfied that 24 hours is enough when the medical profession urge that it should be a minimum of 72 hours and particularly why he has put forward this proposal when it is obvious that since 1945 this provision has caused no difficulty. I am not aware that it has interfered with the rights and liberties of the people concerned.

It is commendable on the part of the Minister to provide that voluntary patients should be able to go voluntarily. But that ignores the peculiar nature of mental illness and particularly the peculiar nature of the treatment that may have to be given to people who come in voluntarily in an emergency situation. These people should not be allowed to sign themselves out. They may be a danger to themselves and possibly to the community and their families until the medical profession is satisfied it is safe for them to leave. The Minister is taking a big risk in reducing the term of notice to 24 hours. I should like him, to spell out for us the medical indications on which he has based this decision to go for 24 hours rather than 72 hours. That is my main criticism of the Bill.

My other main criticism is with regard to what is not in the Bill. Obviously everything that is required cannot be in the Bill, but it makes a poor effort to fulfil the manifesto promise. The people who are involved in this whole area of mental health had expectations that what was promised in 1977 would be delivered. It is a matter of regret, but at this stage not a matter of surprise, that there has been this failure to deliver. This is the one consistency of the Fianna Fáil manifesto of 1977—its consistent failure to deliver honest promises.

Mrs. Honan

I welcome this Bill with great sincerity. I thank the Minister and his officials.

The Bill should be designed to give the best possible attention to the mentally ill while, at the same time, having regard to the working conditions of those with the task to ensure the smooth running of the units and the hospitals. Senator Cooney was most upset about the inclusion of the mentally handicapped child in this Bill and his colleagues in the other House had also the same concern. I will deal with that later. I am amazed they are so unaware that the two areas are separate. This matter needs a reply from somebody who has worked in this area for a long time.

There is in the Bill the provision that great care should be taken to ensure that there is agreement with staff at all times before any centre or unit is designed for a hospital. In the past we have seen buildings empty for years because in the first place there was no working agreement with the staff at the time of planning. It is very important.

I agree that voluntary admission should not be discouraged. There are often many complaints about the fact that anybody can get himself admitted to a mental hospital without being referred to it by a doctor. It seems odd that a voluntary patient can admit himself or herself at three or four o'clock in the morning without consulting his or her GP. However, I agree that voluntary admission is a must. The present system consists of a few minutes visit to a GP and then the patient goes home again with a fistful of tablets or a prescription. No doubt the patient will feel better but the cause of the condition or illness is not being treated and of course it will flare up again. This is something that makes it easy for the doctor but it means only more trouble for the patient.

The provision in section 16 is required but it is, of course, seldom used. It may be necessary in the case of a person who has no relatives and who has opted out of society. If such a person becomes very ill then somebody must step in and deal with him. The gardaí are the obvious choice.

There is nothing new in section 17. There could be the case of a patient who had a brother, sister, or other relative in the hospital and for the betterment of both the patient and the person on the staff it might be better that that patient would be moved to another hospital.

Section 21 deals with escort duty. I am totally opposed to this. If somebody has to be detained, it is a social problem. A person resisting going into hospital has to be arrested and taken in. That is a Garda function only, as I see it. Perhaps I am reading it wrong. This has been debated for long periods. I hope the Minister will be able to re-assure me about this at a later stage. We are sending nurses out to force somebody into a hospital and then we are asking those same nurses and patients to work together. Instead of having confidence in each other from the very start, the situation has been badly damaged before treatment begins. Section 27 is necessary because we have an open door system in our hospitals. Patients can go out at a very dangerous time in the treatment towards recovery.

Section 36 is quite good. It is nothing new. Places have been inspected down through the years. I have strong views on section 38. We must ensure that justice is done. We hear so much talk about justice that I am confused about my rights, your rights, their rights, our rights. I have confidence in the Minister and the officials in his Department who are dealing with this Bill. I have personal confidence in them even if it is only lately acquired. I am very glad there is provision to safeguard against the unnecessary detention of persons. This certainly was abused, and I am glad it is there.

Does the Bill provide that the task of visiting and inspecting mental hospitals will be assigned to a medical officer of the Department by the Minister? Is the Minister happy about the fact that this most important task is to be given to one person? I would be concerned about one person being given that very, very important task. We must remember that some 36,000 persons are currently availing of outpatient clinic facilities. I suggest that we might give even more encouragement to upping this service given by all of us who happen to serve in the field. The Minister referred to out-clinics. It is a very important field and enough emphasis was not put on it before now. Rather than having our hospitals packed with patients, some of them could be dealt with at home by efficient GPs in their own areas.

I come now to Senator Cooney and his colleagues in the Lower House. I did not intend to bring mentally handicapped children into this debate. I have very strong views on this matter and very strong backing from parents of these children who, with all due respect to mental hospitals, do not see their children as mental patients. I agree. After 17 years as chairman of a federation, I can see what I and other dedicated people have achieved. There are very strong views that a mentally handicapped child and a mental patient in a mental hospital are in two separate categories. I want to make it quite clear that I am in no way detracting from our mental hospitals.

People in this House and the other House do not seem to know that the Government have 5,000 places for special residential care, and 8,000 places available in day facilities, including schools. Unfortunately, I have not the figure the Minister of State, Deputy Tunney, said the Fianna Fáil Government have poured into the mentally handicapped field out of the education budget. It must be colossal. In the past four years 580 places became available. In 1980 alone, 100 new residential places and 180 day care centre places came into operation. This is the achievement of the Minister and the party of which I am proud to be a member. This is our record. Capital expenditure on mental handicap has risen since 1977 from £1,400,000 to £6,500,000. Let nobody in any other party say we have forgotten the mentally handicapped children of this nation.

The domiciliary care allowance for the severely handicapped in 1977 was £25 a month. This week it is £45. The disability maintenance allowance was £11.25 in 1977. Today it is £25.30. We have given a service to these children in care. We have dedicated ourselves to them outside of politics. I never mentioned the mentally handicapped in the field of politics until today. I hauled Ministers over the coals for not giving them more service. When the Opposition see fit to bring these children into the field of politics, and even go as far as to talk about election gimmicks, somebody has to stand up and take them on. I am doing that now. There are 998 approved new posts in the service and a further 480 new posts, making a total of 1,478, with a wage bill of £3,257,335, which speaks for itself.

Everyone serving in this field knows a lot more should be done. We have come a long way. I speak from experience of 17 years in the field as a totally voluntary worker. I know what I have seen, and what has been done. I know what still remains to be done. Only a certain amount can be done. I do not accept that we have been lacking in concern for the mentally handicapped. I am very glad to have the chance this morning to speak on this most important Bill. It seems to be important to a few of us only when I see how few Senators are in the House. We are dealing with people who, sad to say, were forgotten for far too long. I served in this field as a public representative elected by the people. I put a lot of long hours and hard work into it and I never brought politics into it before.

I thank you a Chathaoirleach for allowing me to speak. I thank the Minister for trying to deal with a very complex and tough Bill. I congratulate the senior officials sitting behind him. I will finish by paying tribute to the staff who serve in this field. They serve the people of this country, the patients and the children with total dedication and total commitment.

Acting Chairman (Mr. P. Reynolds)

I should like to point out that references to officials should not be made here.

Mrs. Honan

Sorry. I always make mistakes here.

Professor Conroy

I join other Senators in welcoming this Bill. The history of mental illness and mental disturbance generally is a very difficult one. Quite often we still think in terms of attitudes which were prevalent in the past and which are no longer appropriate today. Although great advances have been made in the treatment of mental illness, nonetheless there are many forms of mental illness which, while they may be alleviated, cannot be cured as yet.

Perhaps one of the most important things which happened over the past few years has been the growing acceptance, the growing realisation, that there is not an absolute line of demarcation between mental illness and physical illness. Almost any physical illness a patient suffers from has some mental component, whether it be something as simple as a natural anxiety, or whether it be so great that, in itself, it is the cause of the physical illness. Certain skin conditions, for example, are related to emotional disturbances. We have tended also to draw a totally arbitrary and unwarranted distinction between those forms of mental disturbance which we could readily understand. We could understand someone suffering from a fever being delirious. We could understand someone being obviously mentally incapable and disturbed when suffering from the effects of excess alcohol.

If the person was suffering from schizophrenia, from some form of depressive illness perhaps, about which until recently there was very little knowledge or understanding, we tended to shy away from this sort of illness and put it into a separate category. We were not willing to accept that, perhaps, there was a chemical abnormality causing the schizophrenia, causing the psychosis, which was just as understandable and just as reasonable as the excess of alcohol causing the symptoms and the signs in general behaviour which we associate with alcoholism, or just as simple as the change in temperature, the change in enzymes, the chemical changes which affect the brain when someone is suffering from a severe fever. We were unwilling to make this very real acceptance.

There is still a great deal of virtual superstition or deep emotional feelings when people think of mental illness. We find is very hard to accept the justice in any physical illness. There is a change in blood pressure, a change in the action of the stomach—or whatever it may be. In mental illness there is a physical change going on which we are now begining to understand and which, in years to come, will become much more explicable, much more reasonable.

That is not to say we should necessarily assume that all people suffering from mental illnesses can be treated at the present stage of knowledge just as we would treat someone suffering from some more obviously physical illness such as high blood pressure. We are tending very slightly to swing from the dreadful situation in which someone diagnosed to be mentally ill tended to be put away and locked up. Sadly there are many people who have been placed in psychiatric institutions and who are rarely if ever visited by their friends or relations. One has a certain sympathy with the friends and relations in these circumstances. It can be a very difficult situation. It is one I am glad to say which is changing. Visits to patients in psychiatric hospitals are becoming much more accepted. People are much more willing to admit that one of their relations or friends is in a psychiatric hospital. People are much more willing to treat such a person in a humane and Christian manner and to realise, also, that such people are suffering from an illness just as much as if they had high blood pressure, or a gastric ulcer or whatever.

There is still a certain minority of patients who, for their own sake, or for the sake of their relations, or for the sake of the public at large, are not fit to be released from psychiatric care. We must be very careful here. The Minister has just about got the balance right between safeguards for the individual. In commiting people to a psychiatric institution, one is doing something even more serious than committing them to a criminal prison. One is depriving them of their liberty and, not only that, but saying they are incapable of managing their own affairs.

This is something which must be faced. It must be accepted and it must be realised that there is a small minority of people who must be admitted compulsorily to psychiatric hospitals and who must not be released from psychiatric hospitals unless they are very definitely cured of their illness, or at least sufficiently so that they can take their place in the community. We must avoid swinging from a situation in which large numbers of mentally ill patients were automatically institutionalised to a situation in which we can assume large numbers can be sent out into the community to families who are, perhaps, unable to accept them, or unable to receive them, the community in which they are unable to cope, in which under certain circumstances they may find themselves at so total a disadvantage. One is not doing anything for the patient, or his relations, or the community by releasing him into that community. One is giving a spurious freedom to the unfortunate individual.

We must be very careful indeed to draw this line between the individual's personal freedom and the necessity, in a very small minority of cases, but a necessity nonetheless, to retain for their own sake, for the sake of their relations and the community a certain small minority of patients in hospital. We must also ensure that such patients can readily be admitted to hospital. I have had personal experience myself of the tragic circumstances which can arise in these cases. It is absolutely essential for the sake of the patients themselves, for the sake of their families, for the sake of their local community, that they can be readily admitted to hospital.

There was some mention of the voluntary patient. We must draw a distinction here again between the voluntary patient going into a hospital with a psychiatric illness which he or she believes requires immediate treatment. Such people must have ready access to psychiatric services if they feel they need them. This relates particularly to the point raised by Senator Honan. I would not like to see a situation in which such a person was compelled first of all to go to an outside doctor, was then referred to a psychiatric consultant, and eventually went into hospital. It is very important that they have ready access to treatment when they believe they need it.

There is also the question of discharging patients. Again here we are trying to balance two things: the actual good of the patient from the medical point of view, and his right to personal freedom. The Minister, who has had to take this very difficult decision after listening to his expert advisers, has just about got it right. Such a patient without being well enough to go out into the community might demand to be released. It was initially the Minister's intention that this should be the case, that a person who had voluntarily given up his liberty should be able to regain that liberty once again at a moment's notice.

That was a very understandable attitude, but one which might not necessarily be in the interests of the patient himself or herself. By the very nature of the illness of the patient he or she might not be in a position to decide coherently and rationally whether or not he or she was in fact well enough to go out into the community, well enough to give up treatment. At the same time, there is no way in which such a person should be detained indefinitely without the gravest of reasons. This amendment which the Minister has inserted providing for 24 hours meets the needs of the patient, which are the paramount needs in this situation. It is a very difficult situation.

I must associate myself with remarks Senator Honan made about mental handicap. Unfortunately, we have tended to think of mental handicap as a form of psychiatric illness. This is very understandable, but it is totally incorrect. A mentally handicapped person is not necessarily in the slightest degree psychiatrially disorded and should be regarded and treated in a very different light. It is, of course, a very major and very tragic area of our medical services, but it is a very important one. Certainly from talking with the parents of such people and, indeed, with mentally handicapped patients themselves, I know that one of the things about which they are most sensitive, and quite rightly sensitive, is being regarded as being psychiatrically disturbed when, in fact, they are not so disturbed.

The situation in our psychiatric services is by no means satisfactory as yet. I am sure the Minister would agree that there are many improvements which we would like to make, some of which have been commenced, and others which I am sure we will continue. This is not something that is unique to this country. Psychiatric services generally have tended to be a neglected area of health services right throughout the world. In fact, in many ways we are very much ahead of many other western countries in our provision of hospital beds for psychiatric services, and so on.

This is shown very clearly in Table E6 of the Department of Health document giving statistical information on the 1980 health services. The number of beds in Ireland is 4.8, that is, beds in psychiatric hospitals per 1,000 population for each Member State of the EEC, 1960, 1965, 1970 and 1975. Taking the 1975 figure, it is 4.8 in Ireland as compared with 3.8 in Luxembourg, two in Italy, 2.9 in the Netherlands, 3.4 in the United Kingdom, 1.8 in the German Federal Republic, and 2.5 in Denmark. In fact, in this statistic we compare very favourably. That is not the whole story by any means. I am sure what we would wish to see is a situation in which very few psychiatric beds were needed in our health services.

There are many disturbing figures in Table E3. We note that there is a very substantial improvement to which the Minister has referred. Between 1963 and 1971 the total number of patients in residence fell from nearly 20,000 to 16,600. Nonetheless, one cannot help thinking that many people in that 16,600 under certain circumstances could well be able to live in the community but not all of them by any means. There is this percentage who, in fairness to themselves and in fairness to the community, should under no present circumstances be related.

Another worrying feature of these figures is that 82 per cent of these people are single, suggesting strongly, when you consider the married level of 11.8 and the level of 5.8 for widowed, that one of the elements in this may well be a lack of home or community services to which such people could return. Another very worrying feature is that 50 per cent of these patients are diagnosed in the category of schizophrenia. This is a very high percentage in itself.

Of course, schizophrenia is an illness about which we are beginning to learn quite a lot. There is quite a lot of information coming along about it. Quite a number of therapies are now coming into practical use but, nonetheless, it is by no means a situation in which we can claim to have a cure at this stage of our knowledge. It is one of the conditions to which I was referring earlier about which, in due course, we may be able to realise that there is a definite physical or chemical basis causing this condition just as there is a definite physical or chemical change causing bronchitis, or pneumonia, or high blood pressure, or whatever, and react in a better manner to such conditions as schizophrenia, psychoses, and so on.

I welcome this Bill. As the Minister said, it covers a certain group of patients and is specifically directed towards this particular group of patients who are compulsorily admitted. Particularly in this year and age, it is very appropriate and right that we should bring in a Bill, an excellent Bill, which on the one hand brings up to date our concern for an individual's human rights and personal freedom and at the same time brings up to date the necessary medical therapy and safeguards for the individual and for the community. I commend the Bill.

Minister for Health (Dr. Woods)

I would like to thank the Senators for their very thorough analysis of the Bill and its contents and for some of the relevant points which have been made in the course of the discussion here. I include Senator Cooney, for, while he digressed from time to time, feeling an obligation to have a tilt at the Minister and the Government, he made a very honest attempt to consider and discuss the essence of the Bill and to give us the benefit of his own experience. I welcome his contribution.

Some useful points emerged from the debate which perhaps, if they had been made in the Dáil debate, might have saved a lot of confusion during that whole period. I regretted that confusion because it took from what is a step in the modernisation of our mental health legislation, and a particularly important step in that whole process.

Senator Cooney said that he was concerned about two main elements in relation to the Bill, that the manifesto had promised a complete reorganisation of the mental health services, and a national programme for the mentally handicapped. In this respect I disagree with Senator Cooney, because we have been involved in and embarked on a major programme of reorganisation to assist the mentally handicapped. Senator Honan quoted some of the figures which were given recently in this regard. If you take the whole question of the mentally handicapped services, one of the figures which sticks in my mind is that last year we were providing £6 million for capital services. This year we are providing £8 million. That is money being spent this year.

Senator Cooney was concerned about the various projects which I initiated or advanced during this year. I assure the Senator that it has all been entirely responsible and within the budgeting requirements, both of myself and of my Department, which is taking very seriously and responsibly the level of expenditure involved over the next five years or so. Our total expenditure on capital services has increased very significantly over the last four years. In the current year we are spending £47 million on our health services. Assuming that we maintain expenditure at or about this level then each and every one of the projects which I have either initiated or advanced will be finalised. I want the Senator to understand that. In 1976, admittedly, the level of expenditure was £11.2 million on our capital health services. It is currently running at £47 million. Without any further major increase, other than the likely increases in relation to inflation, in continuing this level of expenditure, we have provided for all these projects.

Adult mental handicapped — I agree with Senator Cooney here — is one of my priority areas. I want to spend the capital on the provision of places for mentally handicapped. The projects which we have started this year in that area amount to £7.7 million. I can provide the Senator with any facts he would like to have and I can bring him to meet the people who are undertaking these works. If you take, for instance, the adult mentally handicapped, we have the Loughlinstown project which I announced as part of this year's programme for the development of the health services; St. Mary's, Drumcar; Cregg House; St. Patrick's, Upton; the Camphill Community; St. Joseph's in Kilcornan and the Western Care Group Home. We have a number of other projects which are being initiated or advanced significantly in the current year. It is a very important part of the overall capital allocation, and the current capital expenditure in that area amounts to £8 million as against £1.4 million which was expended in this area under the previous administration in 1977. It is only fair to put on record that we have made a major commitment in this area, which is evident. I know this very well because I travel a lot to these units. I regard it as part of my work, although I have been criticised in the Dáil repeatedly for doing so. Admittedly, it places a greater strain on me because if I visit one of these units I must get back in a hurry. Nevertheless, it is one of my priorities. I am very aware of the high standard of the work which is being done.

Over the past four years new residential services for children and adults started in Kilkenny, Westmeath, Limerick, Sligo, Roscommon, Kerry, Dublin, Cork, Mayo and Galway. New community hostels came into operation in Wicklow, Dublin, Galway, Kildare and Kerry. In addition, various new day-care and workshop facilities started in Dublin, Waterford, Longford, Cork, Offaly, Westmeath, Kildare, Wicklow, Kerry, Cavan, Meath, Louth, Galway and Donegal. These new places involved the approval of 998 new posts in the service at an additional cost. We can see from that that there has been a major commitment on the part of the Government, in line with that given in the manifesto.

The revenue expenditure on mental handicapped services, has increased from £25 million in 1977 to £60 million in 1980 and it will be higher in 1981. Senator Honan mentioned the increases in the domiciliary care allowance which was recently increased to £45 per month and the disabled persons' maintenance allowance, which not only has been increased but has been extended to cover dependants who were not covered previously. We also had in April 1980 services for the mentally handicapped. The report of the working party was published and it provides guidelines for future planning. It advocates a strong orientation towards community based services and recommends the full development of such services. The important roles of the hostels to enable the handicapped to continue living in the communities is emphasised and some guidance is given as to how this might be done.

On the assumption that community services will be developed to their full potential, the report provides estimates of the numbers of places required for persons who will need residential care. We are working on the basis of this report and proceeding vigorously in that direction. There are various other areas in which funds have been allocated, such as in the early childhood intervention services to which in recent years we have allocated special funds to enable counselling to be developed for parents of young, mentally handicapped children. These were intended to support the families in the management of their young mentally handicapped children and to assist the child's development to the greatest possible extent.

We have some of the most modern facilities in Europe currently in development. I refer any Senator who doubts that to see the work which is going on at Cheeverstown, St. John of God's, Island-bridge, Stewart's Hospital, Palmerstown, or any of the St. Michael House Units. I could list a great number of activities which are taking place throughout the country. I think it is sufficient to indicate that it is an area which we take very, very seriously, an area to which we have given priority and will continue to do so.

One of the major developments in this area which we have and which we have encouraged, promoted and provided finance for, is the provision of psychiatric facilites at general hospitals. The acute units and day care facilities are nearly all provided now as standard. This is a major change and it fits in with the whole approach which is taken in this legislation to mental illness. Already in operation as a result of that programme we have in St. James's, 50 beds, in Castlebar, a 45-bed unit, in Limerick General Hospital, 50 beds, in Letterkenny General Hospital, 50 beds, in St. Vincent's, Elm Park, 30 beds, in Cork Regional at Wilton, 50 beds, Galway Regional at Merlin Park, 35 beds. We have 22 beds at St. Anne's Unit in Skibbereen General. At St. Stephen's, Sarsfield, in Cork, there are 50 beds and, near completion, in Beaumont, 50 beds and in Tralee General Hospital, 50 beds. We are going to build the acute units into general hospitals as a normal part of the scene and obviously legislation is required to complement this development which is taking place on the ground.

Cavan General Hospital will have 65 beds which will include 15 for alcoholics, Sligo General will have 46 beds, which will include 16 for young people and the Mater Hospital, Dublin will have 50 beds. There are various others at different stages in planning and proposals at Nenagh, Kilkenny, Wexford, Blanchardstown, Ardkeen, Waterford, and a number of others where acute beds are planned.

This is an interesting introduction to the whole development which is taking place. It is sufficient to refute any suggestion that we are not undertaking currently a major reorganisation of our mental health services. It shows quite clearly that we are undertaking this major reorganisation. The total cost of those beds over that period will be about £25 million and we are engaged in this complete reorganisation of the mental health services. It does not require legislation, it requires commitment and the will of a Government to do it. This Government are committed to doing it and we also have a national programme for the mentally handicapped. From the figures which I have given it is quite clear that this is a major and extensive programme.

Senator Cooney congratulated the Mental Health Association and I agree with him. They are doing excellent work, we are in very close contact with them and we are supporting them in that work. It is an organisation which is gaining new enthusiasm and support throughout the community which in itself is encouraging it in the work which it is doing. This is very valuable work and I know that Senator Cooney recognises that fact.

Senator Cooney sees great changes and improvement in the psychiatric centres, he sees the walls going away and various other opennesses coming to these centres. That is part of the scene.

He raised especially the question of two doctors certifying the recommendation for reception. He was inclined to think that it might be possible to have one on the spot and one after. I have said, and I would be very concerned, that if you bring in that system, in fact the one on the spot and the one after will become the norm. Undoubtedly, that is what would happen. I appreciate and I sympathise with the views expressed here in relation to this question of two doctors certifying because, from the community point of view, I have been involved. I am with reasonable frequency involved in arranging that people, especially elderly people with whom I work a fair deal, at certain stages have to be admitted, requiring certification. I appreciate there can be difficulties and I know that in practice this requires some extra work on the part of those who are arranging for such certification and reception. Nevertheless, I must balance this against depriving individuals of their liberty and freedom and a small administrative inconvenience to any of us in this regard is a very worthwhile price to safeguard, in so far as we can, the liberty of the individual and to ensure that such admissions are properly protected.

I would like to make clear to Senator Cooney that I introduced the regulations only as a mechanism to deal with any situation which might arise in the future. I do not envisage using them but there were views expressed in the Dáil in relation to this point that there might be some regions of country where it might be more difficult to have two doctors certifying. By providing the power and by giving to the Minister the power to make regulations, we ensure that there will be a means of dealing with such a situation if and when it arises. I did point out in my introductory remarks that it is rather odd to have a difference between a private psychiatric institution and a public one because, even at present, for the private psychiatric institution you must have two certifying doctors. For the public one, under this Bill, you will also need two certifying doctors. The regulations are there as a means of dealing with any anomoly that may arise in that regard. I do not envisage it at present but I made provision for this power in deference to the views expressed by Deputies at the time.

The next major point which Senator Cooney raised was that of the 24 hours' notice in relation to voluntary patients. I hope Senators will appreciate my concern to normalise the voluntary patient as much and as far as possible. I consider that the 72 hours' notice was a very considerable length of time and there was the very strong view that it could act as a deterrent to people going in voluntarily. This is the point that I want to make to Senator Cooney, that while it is extremely rare to have to use it, nevertheless the concern was more on the other side of the coin. The fact that it existed there was regarded as being, certainly in some instances, a deterrent to people going in voluntarily. If we were convinced that it would be to our advantage to go in as voluntary patients, we would like to think this did not commit us to more than that at the time. It might have the effect, therefore, of ensuring that people would go along more readily for treatment at the initial stage.

I should also like to make it clear that the medical profession were quite happy with the compromise arrangement of 24 hours. They felt this was a reasonable arrangement and would be quite workable for a situation that they do not see arising with any frequency but, nevertheless, against which they would like to have some safeguard. That view was reflected by Senator Conroy who said he regarded this as a very reasonable and right provision. I am quite happy that the 24 hours to the person going in will seem more like a normal hospital situation where you would give notice in any event of your intention to go. After some time that should be adequate. I am also advised that if it is a question of providing sedation in relation to a patient who gets into particular difficulty, there is no special difficulty in that regard with modern medicine and therapy. I do not visualise a problem in that regard. I see it more as a deterrent and I hope, in reducing it to 24 hours, that this will be helpful in encouraging people to go in as voluntary patients. This was Senator Cooney's main criticism of the Bill. His view was that it caused no difficulty since 1945 and, therefore why change? I have made clear the reason for changing, which is merely the other side of the coin, that it can act as a deterrent to those who might go in voluntarily and this is something which we do not want to happen.

Senator Honan, who has had long experience in the field of mental handicap, made quite clear the separation between mental handicap and psychiatric illness. It is something which parents would be particularly concerned about. It is true that some mentally handicapped patients may also be psychiatrically ill. This can cause confusion in the minds of people generally. Senator Honan and Senator Conroy drew the distinction very well in this regard. I am sorry we did not have them in the Dáil to make the distinction as clearly there because it would have been very helpful to the debate which took place. Senator Honan raised the question of the escorts and was concerned that the psychiatric nurse would be coming out from a centre to act as an escort and, therefore, the patient going in would see that person as the person who brought him or her in and there would be a bad relationship established from the beginning. It is envisaged that it would be the community psychiatric nurse who would do the escorting and this might meet the point which has been raised by Senator Honan in that regard. The Garda are only called in when necessary.

Senator Honan also paid a tribute to the staff in this field. I have been around most of the psychiatric institutions. I find it difficult to make comparisions but apparently they regard Queen Victoria as the last one to visit them before me and I was made very welcome. I have specially gone to visit the psychiatric centres and all the patients in the centres, including the most disturbed patients. I should like to re-emphasise what Senator Honan said in relation to staff. They do a very difficult task on behalf of the community and one which must be particularly wearing when it has to be done day in and day out, especially when caring for severely disturbed patients. They do a wonderful job. It is marvellous to see the extent to which they are now involving even very disturbed patients in their activation projects of various kinds, whether playing cards or doing jig-saws. They are involved with them in these elementary games and in some cases they go very much further than that with workshops and other developments. There is a tremendous change taking place there and it is a pity the community at large do not recognise the work which is being done. The Mental Health Association are bringing and will increasingly bring, this message home.

Senator Conroy made a very good point when he said there was no clear line of demarcation between physical and mental illness. He said that very frequently emotional disturbances are associated with physical illness. He went on to say that it is now recognised that a chemical abnormality can be and often is the cause of mental illness. When we see that it is a physical base that exists under the abnormality we may then reach a point where we will have a better understanding of mental illness generally.

This is Epilepsy Week and the Association for Epilepsy are trying to get information across to people this week particularly. I should like to congratulate them on the work they are doing. It brings to my mind a point which is somewhat analogous to Senator Conroy's, that we have a great misunderstanding of epilepsy. I have seen a number of cases where totally normal people, boys or young men, who had been playing a game, or riding a bicycle, had fallen on a concrete path or whatever, and developed one of the forms of epilepsy. This may be transient or it may last for a long time. When you see this physical presence as the obvious result of a change in the electrical conductivity or in the electrical mechanism and the electro-chemical situation within the brain, it gives you a better understanding of the situation and a realisation that there is nothing specially strange about such a person. There is actually a clear physical scientific base with which you can associate your understanding of the illness. If we could bring more of that understanding to the community it would help a great deal in getting people to understand mental illness.

For these reasons the debate has been particularly helpful and valuable and it has added considerably to the thinking on the whole question of mental illness.

Again, Senator Conroy was concerned that a patient feeling that he or she needs treatment should have ready and easy access. I would certainly hope that, with the system which is being developed at the acute units within the general hospitals and the other community units, there will be easier and more readily available access in future. Again, he agreed totally with Senator Honan on the distinction between mental handicap and psychiatric illness and this is something for which the parents concerned will thank both Senators very much. As I said earlier, they might be sorry that they were not in the Dáil to make those points as clearly as they have made them here this morning. I agree with Senator Conroy that there is a great need for increased community services. I hope he recognises that that is what we are currently doing and that in so far as the total resources are available to the health services, I will pursue that line and, indeed, might pursue it even beyond that point. That is another question and another day's work. It is very urgent and is something to which we are certainly very much committed.

In conclusion I would like to thank the Senators for their contributions on Second Stage and to recommend the Bill to the House.

Question put and agreed to.

Professor Conroy

The Minister is anxious that all Stages of the Bill go through as soon as possible, today, in fact, if feasible. I wonder whether the leader of the Opposition has any views on this matter?

Mr. Cooney

I have no objection to starting Committee Stage now.

Agreed to take remaining Stages today.