Seanad Éireann díospóireacht -
Wednesday, 13 May 1998

Vol. 155 No. 12

Inspector of Mental Hospitals Report: Motion.

Dr. Henry

I move:

That Seanad Éireann notes with alarm the delay in the publication of the Inspector of Mental Hospitals Report for 1996; calls on the Minister for Health and Children to publish it immediately; and asks that the Leader of the House initiate a debate on the reports of the Inspector of Mental Hospitals now.

I welcome the Minister for Health and Children to the House. I am delighted this motion is being debated this evening as it has been on the Order Paper for some time.

Mental hospitals and the treatment of patients with mental illness are governed by the Mental Treatment Act, 1945. Since 1945 attitudes to psychiatric illness and its treatment have changed dramatically. In the Department of Health's four year action plan for 1994-7 the following was listed as a priority: "To introduce a new Mental Health Act to give greater protection to the civil rights of the small number of people with mental illness who have to be detained for treatment and to bring our legislation into conformity with the European Convention on Human Rights". We have signed the 1950 European Convention on Human Rights and Fundamental Freedoms but we have yet to bring forward the legislation necessary to implement those rights in our law. That we are in breach of the European Convention on Human Rights was acknowledged in the 1995 White Paper, "A New Mental Health Act".

The Agreement reached in the multi-party negotiations on Good Friday in Belfast states in the section on rights, safeguards and equality of opportunity, under subsection (9), that the Irish Government will take steps to further strengthen the protection of human rights in this jurisdiction. It also states that the Irish Government will establish a human rights commission with a mandate and remit equivalent to that within Northern Ireland. The Mental Health (Northern Ireland) Order, 1986, is fully in accordance with the European Convention on Human Rights. Our concern for the civil rights of psychiatric patients and the responsibilities of those who deal with them is 12 years behind Northern Ireland. As one of those who hopes for the safe passage of both referenda, I hope the Minister recognises the urgency of dealing with this legislation.

At present, under the 1945 legislation, mental hospitals are inspected by the Inspector of Mental Hospitals. He produces excellent reports which are part of the social history of our time. He visits all the mental institutions at least once every two years, but many more frequently. For a long time he has held the fort on behalf of psychiatric patients.

There are consistent delays in the publication of his yearly report which, under section 247(2) of the Mental Health Act, is required to be laid before the Houses of the Oireachtas and a copy sent to the President of the High Court. I have been unable to find any reference to a debate on his report in either House, so we are making history tonight. The 1996 report has still to be published so I had to use the 1995 report for this debate.

The inspector's report focuses on major problems but also gives praise. The decline in the number of patients in large institutions is welcomed but the fact that the number of community based residences and day care facilities are not being set up fast enough is noted. He points out that by virtue of the perceived increased level of violence in our society, the rise in the number of homeless, the increasing problem of marriage breakdown and the undoubted increase in suicide rates in recent years, it becomes extremely important that alternatives to in-patient care are quantitatively and qualitatively adequate so that patients do not become homeless and do not suffer social or economic deprivation and are adequately housed and fed. In report after report he highlights the difficulties and lack of staff and the fact that multi-disciplinary teams have not been formed.

It is interesting that purpose built units attached to general and private hospitals come in for far less criticism than the old mental hospitals, so we must be getting somewhere. The inspector recommends in the 1995 report one day place per 1,000 of population and 1.5 residential places. That was the first time he made specific recommendations on the number of places needed in both categories.

Child and old age psychiatry and suicide prevention are covered in the report. There is much comment on the management of the disturbed patient and the need for strict guidelines regarding the use of seclusion, the ultimate sanction on the disturbed patient, and the need to assess its effect on them. A special report on dealing with the disturbed or regressive patient was commissioned in 1995 and was to report in 1996 but I cannot find any evidence of it, although I may not have looked in the right places. I am glad the task force on suicide has reported. The number of adolescents in adult wards is noted. However, I do not see any comment on the lack of facilities for dealing with new mothers with post-natal depression and their babies, despite the fact that we know rapid treatment gives better results.

The inspector's reports are not all complaints. He frequently praises his staff for the work they do in difficult conditions, pointing out the difficulties of keeping old buildings clean and trying to function in acute units with inadequate facilities and staff. There has been little complaint in recent years about treatment, with the possible exceptions of seeking more explanations, privacy for patients undergoing electroconvulsive therapy and the need for strict guidelines on the use of seclusion.

I cannot expect the Minister to give me hope that the system will be improved but there are a few things he could do which would show that we are establishing patients' human rights as a priority. Section 247 of the Mental Health Act requires the inspector to furnish a general report each year to the Minister on the administration of the law and the care, welfare and treatment of persons of unsound mind. This is one area where there are complaints year after year and where, with better management, the civil and human rights of patients could be improved.

Ten years ago when I was on the board of the Eastern Health Board I was involved in inspecting the mental hospitals in its area. I thought huge improvements had been made in terms of a personal clothing policy for patients. However, I regret that policy is not universal. One of the greatest humiliations for long stay patients, that is, patients who have been in hospital continuously for over a year, is the lack of a personal clothing policy. The 1995 report states:

Newcastle Hospital:

Efforts were being made to rectify the unsatisfactory situation resulting from the closure of the laundry service in the previous year. A small laundry was under construction and when this became operational the personal clothing system would be fully restored.

St. Ita's Hospital:

Only some of the patients within St. Ita's Hospital had personal clothing and toilet requisites and greater efforts should be made to ensure that these were provided, especially for long stay patients.

When one considers the difficulty of preventing infection in mental hospitals it is dreadful to think of people sharing toilet requisites. The report mentions it again in relation to St. Brendan's Hospital. It states:

A personal clothing policy to be introduced in all wards of St. Brendan's Hospital. All patients should have personal clothing, night attire, toilet requisites and individual lockers.

The report continues:

The Central Mental Hospital:

Personal clothing and toilet requisites to be introduced for all patients.

St. Bridgid's Hospital, Ardee, County Louth:

Personal clothing should be introduced in all wards.

It is good that St. Patrick's Hospital in Castlerea has closed because the following was the situation in 1995:

The lavatories were dirty, underclothing and night clothing not personalised. The male geriatric sleeping areas were dirty and untidy. Full bottles of urine in a locker and on a window ledge were observed.

The following was the report's analysis of the situation in St. Mary's Hospital in Castlebar:

Concern over the unsatisfactory laundry facilities continued. Overall, the physical facilities of the hospital were most unsatisfactory. The quality of food provided for the evening meal in one ward was noted and was not impressive.

Many of the long stay patients in these hospitals are over 65 years of age and many have few visitors; in fact, approximately one third have no visitors at all. The only hope of their physical conditions being improved is if some attention is paid by the Minister to the inspector's reports.

Another simple recommendation which would help patients, family and friends is identification badges. Lack of these were noted in St. Loman's Hospital in Lucan, St. Ita's Hospital, St. Brendan's Hospital and St. Loman's Hospital in Mullingar, where facilities appear to be bad and staff are working with facilities which the inspector deems to be unacceptable and inadequate for the treatment of patients with acute psychiatric illness. Identification badges are not worn in some wards in Our Lady's Hospital in Ennis, Limerick Mental Hospital, St. Davnet's Hospital in Cavan, St. Senan's Hospital in Enniscorthy, St. Finian's Hospital in Killarney and St. Conal's Hospital in Letterkenny. Identification badges are worn in all hospitals where patients with physical illness are treated. Why does this not happen in mental hospitals? The strategic management initiative recommends that all civil servants should wear identification badges. I have to wear an identification badge when I go into a hospital.

Basic human rights allowing the patient some dignity are being ignored. Again regarding privacy, large wards are still in use in many hospitals and the inspector suggests a correlation between them and behavioural problems with patients. In some hospitals patients sleep, eat and live in the same wards day and night. There are no policies on smoking, meaning non-smokers have to sit and eat with patients who are smoking. This is not allowed in hospitals for physical disorders. Why in mental hospitals? Our European Commissioner, Pádraig Flynn, with his strong views on smoking, I know would support me.

Integration of male and female patients has not been initiated in many hospitals, another sign of the way mental patients are discriminated against.

Senators and members of the general public were very alarmed regarding reports of conditions in St. Ita's Psychiatric Hospital last February. Lack of information on what research was carried out in the hospital, and how and when the ethics committee functions also caused concern. While I can understand Senators wanting to visit there, a quick read of the Inspector's report on St. Ita's gives more than enough food for thought. I described the Minister's reply to my Adjournment debate on St. Ita's as a platitude. The patients in St. Ita's deserve better than that.

On page 211 of the report and on subsequent pages, Dr. Walsh has produced a check list for those who inspect mental hospitals. I wonder how many delegations from health boards use such a list?

Last year when I had Private Members' time I asked that we should debate the Mountjoy Visiting Committee's report. There has been so little action on that report that this year the visiting committee resubmitted it with comments because nothing had changed. One of their main worries is that at least 10 per cent of prisoners in Mountjoy have serious psychiatric illness. It was suggested that a barter system was in operation between Mountjoy and the Central Mental Hospital — when one prisoner goes up there one comes down.

Attempts to repatriate patients deemed suitable for return from the Central Mental Hospital to their present psychiatric services appear to be resisted, holding up places which could be used by prisoners. There is no supported residential accommodation so that suitable patients could be discharged back into the community. It was suggested that the governor's house was available in the grounds and could be made into a rehabilitation residence. If even a small number of places were "freed up" we could avoid episodes such as happened in Mountjoy recently when a seriously ill woman was kept in a padded cell for 25 days before accommodation was found for her in Dundrum.

Another small improvement would be if nurses were re-enabled to give patients their medication to take with them when they are going out for a day or two. Recently nurses have been informed that they must get doctors to write a prescription for dispensing in the pharmacy which can cause difficulties if patients are asked out at short notice.

We have not got a comprehensive mental health service nor is there one which is integrated with the rest of the health service. Hostels are not integrated into the community; who has responsibility for them? There is much to be done but if the Minister would see his way to help dignify the patients' lives I would be extremely happy.

Mr. Norris

I second the motion. I believe the Minister has the good will to address this problem, he seems to be a humane, intelligent person who doubtless is aware of its scope and nature. I compliment Senator Henry for raising this important matter in the Seanad where it can be appropriately discussed and information exchanged. It shows her courage, humanity and professional dedication.

It would be unfortunate if this matter was put to a vote. I do not think psychiatric patients in these institutions should be seen to be made a political football. I understand the feeling of the Government side. Perhaps it could be addressed. I appeal to the Acting Leader to consider withdrawing the amendment so that we can do something positive on behalf of the patients.

The Government amendment would open it up to a certain element of ridicule because I do not see how it can welcome a publication which was targeted for 1996 and is still only forthcoming. There is nothing to welcome. Occam's razor, that wonderful philosophical principle that you cannot legitimately discuss the hypothetical use of the non-existent, comes into play. We cannot discuss the report.

In light of that, the amendment could be withdrawn if my colleague could see her way slightly to alter the terms of her original resolution to remove any tendentious suggestions in it —"notes with alarm" and "calls on the Minister" perhaps would raise a hackle. If Senator Henry was prepared to accept an amendment to say that Seanad Éireann "notes the delay" and "asks the Minister", that would be sufficiently mild and drained of any suggestion of rebuke and the Minister and acting Leader could take it on board.

Despite the difficulties this country has a proud record. Until Jonathan Swift set up St. Patrick's Hospital, throughout Europe the mentally ill were regarded as items for sport and recreation or possessed of devils. Swift was the first person to establish, in Dublin, a hospital where mental illness was properly regarded as a counterpart to physical illness and not some form of evil or destructive tendency on the part of the unfortunate patient.

If this debate creates a situation where we assist the Minister and the Department by putting sufficient pressure on them so that these reports come out with greater regularity and in a shorter time space, then it will have done something useful. My colleague, Senator Feargal Quinn, will no doubt talk about this. In many items of legislation where reports were to be produced, he made the point as a businessman that if a report cannot be produced within six months, the idea should be scrapped. I may have misquoted him but he is well able to correct me if I have.

The reports of the inspectorate are extremely important in terms of getting information to the general public so there is a standard against which we can measure progress. At the back of the Inspector of Mental Hospitals Report for 1994 there is a checklist which shows his humanity. We do not know, however, how many of the questions on this checklist have been answered. At the end of every hospital examination he produces a list dealing with areas such as toilet facilities, clothing, the general state of repair of the physical apparatus, etc, and we simply do not know from year to year whether these concerns have been appropriately addressed.

I raised this matter in concert with Senator Henry some time ago in relation to St. Ita's. I noted that it was said this morning that the issue was raised in the context of a by-election. Neither Senator Henry nor myself was standing in the by-election. We raised it because we were concerned, having read reports — two years after the last report of the inspector — that these conditions still existed. Almost immediately Maureen Browne of the Eastern Health Board contacted me with some useful information about St. Joseph's Hospital: the amount of money being spent, the conditions, the number of patients and so on. I have eight pages of a detailed fax here but I should not have to rely on this type of source for information. It should be in the report of the inspectorate and available to every Member of the House as rapidly as possible.

The concerns expressed by Senator Henry are clear and appropriate and some of them have been mentioned time and time again. She has taken them from the 1995 report. I noted them in the 1994 report. Obviously, such simple things as identification badges, which simply humanise the service, had not been addressed.

In the 1994 report a couple of things strike one immediately. One of these is the enormous reduction in the number of patients in hospital — from 21,000 in 1958 down to 5,581 in 1994. Some of the concerns in that report relate to medical case note reporting. The report states that there were instances in several services where documentary procedures in relation to mental case notes were unsatisfactory; that mental case entries were often insubstantial, conveying little information as to the circumstances under which patients were admitted and quite often giving no information as to when they were discharged; and that occasionally entries on newly admitted patients were infrequent and did not form a substantial record of the clinical condition in progress. I would think that is extremely worrying, although the Inspector later paid tribute to the work of the medical staff.

Obviously I will not have time to deal in any great detail with the contents of this report, but, for example, on the number of locked wards involved, how can people sustain humanity inside a locked ward? It would seem to me to be difficult and challenging for the staff as well as for the patients.

Another matter which I would like to raise is the contribution traditionally of religious orders. I know the Minister has visited these places. I have had occasion to visit places like St. Loman's Hospital and see what is conveniently tidied away from our eyesight. These are not people with nice, Hollywood-style, photogenic mental difficulties. Some of these are people who have physical deformities also and they are disturbing. The sounds they make and the level of their intelligence is distressing to witness, as is their distress. Traditionally, there have been wonderful people, many of whom belong to religious orders, who have looked after these people.

Page 6 of the 1994 report refers to St. Brendan's Hospital and St. Ita's Hospital, Portrane. It states that the conditions were of concern; that some upgrading and refurbishment had taken place at St. Brendan's Hospital and that considerable similar work had taken place at St. Ita's Hospital, and was ongoing on the day of inspection. The report further stated that it would go some way to improving the overall internal appearance of the hospital but that much remained to be done. This House knows — and, thanks to Senator Henry, has had it brought again to its attention — that as we speak there are serious problems at St. Ita's Hospital. The argument is made that because they may be closing down some of the units, the work is not economically worthwhile. It tugs at people's humanity. Even if after a year or 18 months they are closed down, the mental horizons of these people will be brightened by having some degree of amelioration.

I join the appeal to the Minister, who I know is sympathetic. This is by no means a partisan motion. Unfortunately, I will not be here for the vote if there is one, for which I apologise to the Minister and you, a Chathaoirligh. If the Minister can find a form of words which would avoid a vote — not just because I do not want to be recorded as not being here — it would be in the interests of the humane motion of Senator Henry to let it go through in some form which allows us all to support the needs of these people.

Dr. Fitzpatrick

This side of the House is prepared to accept what Senator Norris proposed, if I heard him correctly, that is:

That Seanad Éireann notes the delay in the publication of the Inspector of Mental Hospitals Report for 1996; asks the Minister for Health and Children to publish it immediately; and asks that the Leader of the House initiate a debate on the reports of the Inspector of Mental Hospitals now.

Dr. Henry

Of course I would be delighted to accept it. This was not put down in a party political spirit and, after all, I am an Independent. This was to get these reports discussed.

An Cathaoirleach

Thank you, Senator, for clarifying the position.

Mr. Norris

I am happy both Senator Henry and the Government have accepted that.

An Cathaoirleach

Senator Fitzpatrick, to speak to the motion.

Minister for Health and Children (Mr. Cowen)

As amended.

Dr. Fitzpatrick

I welcome this motion. I am a new Member of this House and I was amazed to hear that the report of the Inspector of Mental Hospitals has never been debated in either House since the foundation of the State.

The inspectorate of mental hospitals is one of the jewels in the medical crown of Ireland — it predates the foundation of the State — because it is the only independent review of mental hospitals. As the previous speaker stated, mental problems and disease tended to be swept under the carpet in Ireland in the last century and right up to the 1960s and those suffering from it were confined to the large bins, the county homes or hospitals, where the "out of sight, out of mind" view operated. This is not to say that, by the standards of the day, they were treated badly by the staff. We are extremely lucky in Ireland. We have highly-skilled, highly-motivated and highly-trained psychiatric staff, both medical and nursing.

The problem with psychiatry is that it is not a glamorous branch of medicine. It does not have the same kudos or televisual intensity as cardiac surgery or accident and emergency, but the skills required to practice psychiatry, while understated and not always obvious to the untrained eye, are quite remarkable. The fact that people who practice psychiatry can deal with patients, who are often disturbed, in difficult circumstances and with little technical backup is not often understood by people.

I said that psychiatry was not the most fashionable branch of medicine but sometimes it is prey to whims of fashion. I am nearly 30 years in general practice. I have seen the huge changes in the treatment of psychiatric patients, 90 per cent of whom have been the better for it. The standards of treatment, the medication and the conditions in which patients are treated have improved in my lifetime beyond all recognition. However, in the 1960s a fashion called "community psychiatry" was introduced and I think we went overboard on it. The theory was that everybody with a mental illness could be treated in the community. As I said, that is the case for 90 per cent of them, but there is a percentage which needs care in structured circumstances. We nearly threw out the baby with the bath water.

I am convinced it is no accident that today we are building prisons while closing down psychiatric institutions. Many of the people who are consigned to prison by the courts would be better off in a caring psychiatrically run institution. It is also no accident that prison officers are being given necessary basic psychiatric training. However, we have moved on and I would not like to turn the clock back; but when we make great moves in medicine, we should take a view of the wider picture also.

Earlier I welcomed the idea of an inspectorate of mental hospitals. In his time in the Department of Health and Children, the Minister might take a look at that inspectorate and see if it can be applied across the spectrum of medical care and treatment. There are the general, specialist and private hospitals which could come under a medical inspectorate to see that they reach a certain standard of care in their dealings with patients and the community.

In his report the Inspector of Mental Hospitals comments on the public areas in psychiatric hospitals, the corridors, toilets, general areas and even sleeping accommodation. Senator Henry mentioned items like soap, bed linen, night attire, etc. An inspector should not have to mention these basic items in his report. I do not know why public areas cannot have the same hygiene standards as hotels. In general hospitals are well staffed but the standard of general upkeep of the communal areas falls below a level that is expected and is tolerable in modern society. I am talking about general maintenance such as a coat of paint and a standard of cleanliness for walls, halls and floors that should be adhered to and reported on daily.

Other Senators have already mentioned points I wanted to raise and I will not repeat them. I am glad this motion, as amended, will be passed through the House without opposition.

Minister for Health and Children (Mr. Cowen)

I thank Senators for providing the opportunity to debate the important work which is undertaken by the Inspector of Mental Hospitals. I understand that my Department received a recent inquiry from the office of one of the Senators who raised this matter and the inquirer was assured that it was intended that the 1996 report of the Inspector of Mental Hospitals would be published within two weeks. That remains the position and I am pleased to inform the House that it is my intention to lay the Annual Report of the Inspector of Mental Hospitals for 1996 before both Houses of the Oireachtas on Monday next, 18 May 1998.

I wish to acknowledge the influence of the inspector in the improvement in standards of care in our mental health services. This improvement is again documented in this latest report which is most encouraging. I also recognise the importance and benefit of publishing the Inspector of Mental Hospitals report within the year following inspection and I would like to assure all Senators that I am committed to its publication as soon as possible after the inspections of individual facilities are completed and reports are compiled.

I acknowledge that delays have occurred in the production and publication of the annual reports and I am taking steps to improve the situation. For example, in 1997 the timescale between the issue of the draft report to the service providers and the final report being drawn up has been reduced under my tenure from four months to two months. That should speed up the final publication of the 1997 report some time later this year.

I should explain that the 1996 report has been ready in draft form for some time but because of the workload at the printers, the final printing of the report has taken longer than expected. Referendum and other issues have taken precedence. The annual report of the inspector for 1997 is at present being collated and I intend to have it published as soon as possible within the current year.

The role of the Inspector of Mental Hospitals in relation to standards in our mental health services is of great importance. The inspector is required under the Mental Treatment Act, 1945, to carry out in-depth inspections of all public and private hospitals and units in the country, including the Central Mental Hospital. Public psychiatric hospitals and units are inspected annually while private hospitals and the Central Mental Hospital are inspected twice yearly.

A detailed report of each inspection, with general comments and recommendations for improvements in services, are prepared by the Inspector. These reports are forwarded to the chief executive officer of the responsible health board or voluntary hospital in respect of public psychiatric facilities and to the persons in charge of private facilities. In each case a response to the comments made by the inspector and his recommendations for improvements in services is requested. In some cases, meetings are held between my Department, the inspectorate and the health board to discuss improvements in the hospital and associated services. The reports of individual inspections are then summarised to form the inspector's report. It will be clear, therefore, that issues raised by the inspector during inspections are followed up following preparation of individual reports and do not await publication of the annual report.

Nevertheless, Senators will appreciate that the whole process of compiling annual reports takes time to complete but, as I indicated earlier, I am taking steps to speed up the process. The thoroughness and high standards of the present inspectorate have had a major impact in bringing about change in how we care for people with mental illness. The reports encourage greater co-operation between medical, nursing, paramedical and administrative staff in the interests of improving patient care.

In his report for 1996, the inspector highlights and is complimentary of the further improvements which have taken place in the mental health services. The inspector notes the continued development in 1996 of a comprehensive and integrated community based mental health service. This was characterised by the ongoing reduction in the number of patients resident in psychiatric hospitals through rehabilitation of long-stay patients, the transfer of acute psychiatric hospital care to acute units in general hospitals and the further extension of community based services. The number of patients in psychiatric hospitals has fallen from 6,879 in 1991 to 5,047 in 1996.

The inspector welcomes, in particular, the opening of a further two new psychiatric units at Bantry and Navan General Hospitals during 1996 and while recognising that progress has been made in developing acute psychiatric in-patient facilities, he indicates that much remains to be done. While the inspector is pleased to note the opening of ten additional beds in a new unit in the Central Mental Hospital, Dundrum, Dublin, he is concerned about the reluctance of some mental health services to accept the transfer of patients from the Central Mental Hospital to their local service when they no longer require the specialist services provided at that hospital. This is an issue which my Department is pursuing with health board management.

He comments favourably on the continued extension of the registration diploma programme in psychiatric nursing and the establishment of a central nursing application centre. The inspector welcomes this challenging period in psychiatric nurse education and training. He acknowledges in his report for 1996 the continued development of community based mental health services. He is however, critical of physical conditions which still pertain in certain areas of psychiatric hospitals, particularly St. Loman's Hospital, Mullingar, and St. Brendan's and St. Ita's Hospitals, Dublin.

I am particularly pleased to say that considerable progress has been made by the health boards concerned in the intervening period to upgrade both the accommodation and facilities at each of these hospitals. The no fixed abode unit at St. Brendan's Hospital has been refurbished and the day programmes and outreach services for homeless mentally ill have been transferred from St. Brendan's Hospital to a much enhanced community facility at Usher's Island. Units 1A, 2A and 10B at the hospital have closed and patients have been relocated to more suitable accommodation. Special care units for the assessment of the disturbed mentally ill were also commissioned in the intervening period.

Substantial refurbishment and upgrading of accommodation was undertaken in St. Ita's Hospital. Community based services were further developed with the acquisition of several community residences, a new day hospital opened in Swords and similar facilities were commissioned for Balbriggan and Coolock.

I note what the Senator has to say about the last time we discussed this issue here. In October last I was the first Minister to visit St. Ita's Hospital in over 20 years — with no reference to by-elections or anything else. Following that visit where I saw the facilities on the campus at first hand, I recently provided capital funding of £550,000 to enable improvements to be carried out to the admission and assessment facilities which was identified as the area in most need of assistance on the day I visited the hospital. I hope this measure will not be regarded as a pious platitude.

I have also initiated discussions for the provision of a modern acute psychiatric unit in Beaumont Hospital to replace acute in-patient facilities which are at present provided at St. Ita's Hospital.

In relation to my visit to St. Ita's, I met all the staff and patients, talked to them and discussed issues with them. I encouraged the staff not to have their morale further sapped by slanted and unrepresentative comments in the media at that time. These media reports were sensationalist and unfair. I do not regard St. Ita's as being bereft of problems. Of course it has problems but the staff are entitled to recognition of their professionalism, the fact that it is an old institution for a different time, that it is an institution in transition and that the Eastern Health Board has medium to long-term plans which are in progress in relation to developing further residences on that site. I met with the chief executive officer of the Eastern Health Board and the Inspector of Mental Hospitals back in September and October, long before St. Ita's became a fashionable topic of discussion in some quarters; I do not include Senator Henry in that. I have arranged for progress to be made and, on foot of my visit there, real improvements will continue to be made at St. Ita's.

As far as mental handicap services at St Ita's Hospital are concerned, plans are in place to provide for the transfer of between 120 and 150 clients from the hospital to new residential services off-site and the provision of both new and upgraded residential services and day services for between 150 and 180 clients remaining on the St Ita's campus. Senator Fitzpatrick correctly referred to the need to carry out small capital works which will upgrade basic facilities to what we regard as normal and a special maintenance programme has been established for the mental handicap services in the hospital. I have made £250,000 available for this programme in the current year. I hope there will be some recognition that we are doing something about the problem.

The Midland Health Board has carried out general upgrading of the admission unit at St Loman's Hospital to include re-roofing and replacement of windows and further improvements are planned in respect of admission facilities and in a number of other ward areas.

The Inspector of Mental Hospitals has a crucial role in improving the quality of life for each individual through the provision of a high quality, patient-centred mental health service. Since becoming Minister for Health and Children, I have taken the opportunity to visit a number of psychiatric hospitals and have seen the commitment of professional staff to the provision of a high quality service. As I acknowledged at the PNA and the SIPTU conferences, I accept that further investment needs to be made in upgrading or replacing some of the physical facilities and that greater capital investment is required to provide the community based infrastructure required to deliver a modern mental health service. I have already this year committed additional revenue resources to further develop the mental health services in a number of specific areas.

The increasing number of people living to advanced old age will require the development of specialist mental health services which will meet the specific needs of older people. Psychiatry of old age is, therefore, a key area for development and I have committed an additional £1 million this year to enable a start to be made on the establishment of specialist services in health boards where no such service had heretofore existed. As people live longer, there will inevitably be an increasing level of functional mental illness and dementia and I intend to give priority to the development of appropriate services to deal with this problem in the allocation of resources in the coming years.

A significant increase in the number of specialists in the psychiatry of old age with associated multi-disciplinary professional teams, together with appropriate facilities, will be required on a phased basis over the next few years to meet service needs. I intend to begin that work in the near future.

With the increasing pressures on young people, I also accept the need to improve our responses to their mental health needs. In this connection, my Department is in the process of preparing a development plan for child and adolescent psychiatry which we hope to make a start on next year. Priority will be given in the plan to the provision of services for adolescents. In the interim, I have provided some development funding this year to meet urgent requirements in a number of health boards.

The report Planning for the Future— on which the development of the mental health services is based — recommended a community oriented mental health service as an alternative to institutional care for persons with mental illness. Senator Fitzpatrick's point that there will always be a requirement for acute mental services for the most mentally disturbed people is well made. Although progress continues to be made in the provision of a community-based service as envisaged the report, we must make further progress before a comprehensive community-based service is available in all health board areas. To that end, I have committed an additional £3 million in revenue funding this year for the enhancement and development of community based mental health services. This is being used in the main to provide additional medical, paramedical and nursing support staff.

The type of service espoused in Planning for the Future will require the provision of additional facilities such as acute psychiatric units attached to general hospitals, day hospitals, day centres and community residential accommodation. I am in the process of finalising my Department's capital programme and I hope to be able to announce in the near future the provision of capital funding, greater than that provided by any previous Administration, to enable a range of such facilities to be put in place. I trust Senators will accept that the Government is committed to the objectives of Planning for the Future to provide a comprehensive, community oriented, integrated mental health service which is caring, effective and ready to meet the needs of modern society.

The principles of equity and accountability are also essential to the provision of an effective health service. The Inspector of Mental Hospitals has played a crucial role in monitoring and reporting on the quality of care in our mental health service each year. In pursuance of excellence in care delivery and to assist service providers in attaining this objective, the inspectorate has in recent years formulated guidelines on good clinical practice and quality assurance in mental health services. The inspector now believes that it is appropriate to formalise this checklist in the form of a guide towards good practice and quality assurance. Senator Norris made an associated point in this regard. Accordingly, I hope in the near future to launch these guidelines and have them circulated to all mental health service providers in the country. At the conferences of the various psychiatric nursing unions I indicated my interest in obtaining members' observations in respect of the final draft, which has come about as a result of a long period of consultation with the service providers.

The 1996 report refers to the plan for a new Mental Health Act and I would like to inform Senators of the Government's intentions in this regard. It is proposed to introduce new mental health legislation which will set out a modern framework for the care and treatment of those suffering from psychiatric illnesses. The legislation will narrow the criteria for detaining mentally ill patient because, as Senator Henry pointed out, the criteria currently applying are considered to be too wide in scope. The proposed legislation will also bring Irish legislation in respect of the detention of mentally disordered patients into conformity with international conventions on human rights.

Since the publication of the White Paper, a draft general scheme and heads of a new mental health Bill were approved by Government. The new Bill is currently being drafted in the Attorney General's Office and it is my intention to have this Bill introduced in the Oireachtas as quickly as possible. As far as I am concerned, the Bill will be given priority by the legislation committee chaired by the Chief Whip.

The inspector's report also refers to the work of the Task Force on Suicide, the final report of which I published earlier this year. The publication of this report marks the completion of detailed examination of the incidence of suicide and attempted suicide and outlines a comprehensive strategy to reduce the incidence of these in Ireland. All statutory agencies with jurisdiction in suicide prevention strategies have been contacted to encourage them to implement the recommendations in their respective areas as a matter of urgency. The chief executive officers of the health boards have, at my request, established a National Suicide Research Committee which will review ongoing trends in suicide and parasuicide, co-ordinate research into suicide and make appropriate recommendations to the chief executive officers of the health boards. It is clear from the task force report that our mental health services will have to be made more accessible to address the needs of vulnerable people at times of crises.

I hope that a co-ordinated response to the recommendations of the task force will help to deal with this significant public health problem. My Department will be following up on the implementation of the recommendations of the task force with the relevant agencies.

With regard to St. Loman's, I share people's concern to improve facilities for long stay patients at that hospital. Members will be aware that a proposal was submitted by the board in respect of the Meath and Adelaide Hospitals, incorporating the National Children's Hospital, regarding the possible deferral of the transfer of patients from St. Loman's to that excellent facility I visited earlier in the week. I assure the House that what was built for the patients of St. Loman's will be given to them. If there are other problems which must be dealt with in Tallaght, they will not be resolved at the expense of the voiceless patients of St. Loman's who are entitled, as a matter of priority, to be transferred into that hospital. The board has indicated, as a result of consultations with my Department, that their transfer will be facilitated.

Reference was also made to problems in Mountjoy Prison. These problems have arisen as a result of the lack of consultant psychiatric input into the prison. We are engaged in discussions with the Department of Justice, Equality and Law Reform and the Eastern Health Board regarding the development of a proper forensic psychiatric input into Mountjoy and other prisons. We hope to take positive steps in that regard in the near future and we would like to appoint a consultant psychiatrist with a sessional commitment to Mountjoy Prison as a means of dealing with that problem.

Senator Henry raised a number of issues in respect of personal clothing and identification badges. As already stated, we shall shortly be issuing guidelines on good practice which will cover these issues based on the checklist to which Senator Norris referred.

It is recognised that there is a need to disperse services currently provided at St. Brendan's Hospital. These plans involve switching acute services currently provided at St. Brendan's to a new psychiatric unit at St. Vincent's Hospital, Elm Park, and at James Connolly Memorial Hospital, Blanchardstown.

I welcome this debate. It gives Senators an opportunity to comment generally on mental health services. I do not like delays in the publication of reports in any Department, particularly when there are statutory obligations to do so and I have taken steps to reduce the delay by 50 per cent. The 1997 report will come on stream. I will take responsibility for those reports which arise during my tenure while doing my best to make up for my predecessor's laxity.

Mrs. Jackman

I was glad to hear the Minister's statement before I made my contribution. I was the Senator who rang his office to find out what had happened to the report and the reason for the delay. I am glad Senator Henry raised this issue. This debate does not give us an opportunity to debate this matter in the detail we would like. I read the inspector's 1995 report in the last few days and the White Paper on a new mental health Bill. It is imperative that those of us with an interest in health and children are au fait with these issues.

I am also glad that there will not be a vote on this motion. This proactive decision by Senators Norris and Henry and those on the Government side ensures that we will not vote on such a sensitive issue. This is indicative of the interest in this debate and Senator Henry's objective of debating psychiatric services in a caring, compassionate manner.

I accept the Minister's comments on the demands arising from other publications concerning the two referenda. However, the 1995 report by the Inspector of Mental Hospitals was not published until 1997. There always seems to be a two year delay.

Mr. Cowen

It depends on the Administration.

Mrs. Jackman

I do not mind which Administration is in power but this was not the only report delayed.

Mr. Cowen

I am trying to raise the Senator's hackles.

Mrs. Jackman

I am glad that the Minister stated that the health boards do not have to await the publication of the report to get involved proactively in implementing the findings. There may be all the good will in the world on the part of the health boards but many of the recommendations require a great deal of financial input. I hope the Minister prioritises mental health for investment.

The introduction to the 1995 report by Dr. Dermot Walsh indicates that he is an extremely caring individual. He must have a huge workload as he is doing this alone. He states that the 1996 report to be published on Monday — and I accept the Minister's word on that — will be his eighth report. Obviously Dr. Walsh has a chronological, coherent assessment of what needs to be done. I do not know him but he must have a tremendous commitment to spend his time visiting health boards and drafting detailed recommendations. The Mid-Western Health Board indicated that health boards have six to eight weeks to respond to these recommendations before they are collated into a report. This involves a tremendous amount of work.

The White Paper states that more duties will be assigned to the inspector. The legislation has been in place since 1945 and I agree that it is time the inspector was afforded the new title of Commissioner of Mental Health Services. The White Paper also indicates that quality assurance will be central to his role and that the position will be given statutory basis in new legislation. This may have been done already as the Minister referred to the fact that he had a statutory role in ensuring the publication of the report. The White Paper also indicates that the commissioner will be a consultant psychiatrist with a distinguished reputation. I hope Dermot Walsh continues in the post for some years. I do not know his age but I would like to meet him as he is making tremendous recommendations on psychiatric services.

The White Paper also refers to the quality of care for all detained patients. These are the people I am most concerned about. There are still 200 patients in St. Joseph's Hospital, Limerick, but we had hoped that there would have been fewer. I know that 36 of these patients are going to Lisnagry. They may already be there as the previous Minister allocated the resources, funding and staff to ensure that mentally handicapped patients would be catered for in Lisnagry and that this policy would be continued.

A second recommendation by Dr. Walsh concerns acute, in-patient admission facilities in general hospitals. Some work has been done on this in the Regional Hospital and in Ennis. The third point concerns Unit 5B for short-stay patients — two months or perhaps more — where patients are based in the community. Work has been done in the three areas referred to. We have seven or eight patients in the community based service in Ferndale, Limerick. This is working extremely well and the Mid-Western Health Board hopes more patients will avail of such services. Peter Kirwan, the psychiatrist in St. Joseph's, has worked extremely hard over the past few years. He hoped that progress would have been quicker but it all comes down to resources.

I would like to repeat Senator Henry's quotation from the 1995 report as it is very important. Dermot Walsh states:

. there is always apprehension that the rate of provision may not keep pace with the decline in in-patient facilities, particularly with the phasing out of the former large mental hospitals and their replacement with short-stay acute psychiatric units of smaller size. [This is an extremely important sentence. ] By virtue of the perceived increased level of violence in society, the rise in the number of homeless, the increasing problem of marriage breakdown and the undoubted increase in suicide rates in recent years, [the Minister referred to this] it becomes extremely important that alternatives to in-patient care are quantitatively and qualitatively adequate so that patients do not become homeless, [There are a number of patients who may have been in, or may need, psychiatric institutional care wandering the streets. ] do not suffer social or economic deprivation and that they are adequately housed and fed.

This is stark language and I am glad Dr. Walsh stated this in his opening chapter. These are the issues with which we must deal.

There is one other harrowing fact to which I would like to refer. Dr. Walsh states that he his concerned at the lack of multi-disciplinary teams in many of our mental health services. In the 1995 report he highlights a health board with responsiblity for four services for which there is no social worker. I hope this matter is addressed in the 1996 report. Dr. Walsh states that this problem has been repeatedly pointed out in successive reports and it is important that it is addressed. I hope that it will not be long before the Minister returns to the House to respond to the recommendations made by Dermot Walsh in the report which the Minister has indicated will be available next Monday.

Mr. Farrell

Ba mhaith liom fáilte a chur roimh an Aire go dtí an Teach. Tá súil agam go n-éireoidh leis san obair mhór atá ar siúl aige. I congratulate the Minister on the work he has done. No Minister for Health and Children will ever have enough money for all the things they will want to do with the health service.

I have been involved with the health service for over 20 years and have seen huge improvement and change. I remember when mental hospitals were the only institutions for mentally and physically handicapped children. In fact, all people with such handicaps were admitted to a mental institution, which is shocking. They were terrible places with big, long wards with rows of beds. I am glad they are no more.

The problem with the mental health service seems to be confined to the Eastern Health Board area. I pay tribute to the board and its staff for their work. Dublin is a huge city with many problems with which they dealing. They are doing their best to integrate mental patients into the community. While community care is good, it must be asked whether the community cares. When there is an attempt to open a high support hostel in an area, people object stating they do not want mental patients in their area because their children would be put in danger. The North-Western Health Board was one of the first to introduce the hostel system and we experienced problems for a number of years. In the past four or five years patients have been welcomed with open arms because it is now realised there is no problem.

High support hostels are a great service for mentally handicapped and mentally ill people but they are expensive. Unless they are set up properly, as they are in the north-west, with a good support service, they will not work. The patients need constant supervision and for someone to cook their meals, clean their houses and ensure they take their medication. There are two or three such hostels in my local village of Grange. It is great to see these people going to the local pub for a drink and being part of the community. This is as it should be. It is unfair to tag mental patients as being unsafe. They are ordinary people except that they must be cared for and that is being done. Mental hospital staff deserve congratulations for the high standard of care they give to patients.

One noticeable development is that not as many of those who are admitted suffer from what I call real mental illness. I am told that up to 40 per cent of patients are admitted to mental hospitals because of alcohol abuse. Alcohol and drug abuse are costing this country millions in terms of health services. A good education programme must be set up to bring home the dangers of such abuse to children and young people. Young people are drinking more than ever and a brake must be put on it by making them understand that they will end up in mental hospitals or rehabilitation units if they do not give up drinking or learn to respect it. Alcohol is a dangerous substance if it is abused and such abuse is a placing a strain on the Minister's resources.

The problem can be remedied because it is a self-imposed disease. People who abuse substances know they are doing so. They should not abuse substances and that must be put across to young people. Anyone who watched "Prime Time" last night will have seen that five people were killed in one accident because three were out of their minds on drink. Alcohol abuse is a serious problem, and if we want to solve our health problems, remedial action will have to be taken to try to educate people to watch their health and not to be a burden on others. If that was done and the abuse problem solved, there would be more money to spend on people who are genuine patients in that their illness is not of their own making. Money for that should not be spent on detoxification programmes and drying out people who drink too much and getting them back on the rails.

I appeal to the Minister to embark on a comprehensive education programme to come to grips with the abuse of substances. Drugs is another problem and much is being done about it. I pay tribute to the Garda and the work it is doing. However, if the problems are not stopped, all available money will be spent dealing with self-imposed problems. There must be a good education programme to teach young people to know when they have had enough to drink and to stop abusing alcohol.

I believe we are streets ahead of any other country in terms of the community care area of patient services. We have a great health service and I pay tribute to the Minister's predecessors. All whom I have known since I first became involved in the health service have done their best and have provided a great deal of funding. Some 20 years ago we took over buildings which were badly neglected and a mental health service in which patients had to sow and harvest crops to feed themselves. Mental hospitals were self-financing and self-sufficient; they could not have existed otherwise. They were like the small farmer; they had to be self-reliant. There is a huge difference between that situation 20 to 25 years ago and the health service we have today. I ask people to look back on the past years and see the wonderful work done in the health service. I pay tribute to everyone involved.

I am glad there was no criticism of the care of mental patients in the North-Western Health Board region in 1995. It has improved a great deal since and we look forward to the new report which will be issued next week because I believe the board sets a good example of how the health service should be run. We have run it well over the years and I have no doubt our service will keep ahead of the times.

I congratulate the Minister on the work he has done and I hope he keeps it up. If the best use is to be made of the resource, I appeal for greater sense and a greater realisation on the part of people so that they will stop abusing substances and, consequently, the health service.

Mr. Lydon

I welcome the Minister to the House. He has been one of the more dynamic Ministers and has already left his mark on the Department of Health and Children.

I wish to make a few short points in the time available. The Minister stated that public psychiatric hospitals are inspected annually while private hospitals and the Central Mental Hospital are inspected twice yearly. Why is that the case and why are not all places inspected twice yearly? We cannot shy away from inspections and the Inspector of Mental Hospitals generally does a good job.

I am glad the Minister has given a commitment that reports will be provided more speedily in future and that, irrespective of whose fault it was in the past, they will be available within the year in which the inspection takes place. If the inspections are to mean anything, and inspections indicate that changes might be necessary, it is no good implementing the recommended changes in ten years' time but just after the inspection is made. I am glad to see the Minister's commitment in that regard.

Many people have spoken about various aspects of psychiatry and psychiatric practice. I have worked in that area for the past 25 years, both in public and private practice, dealing with children, adolescents, adults and in the psychogeriatric area. Although I am not an expert I have some considerable experience and a good deal of expertise.

As the Minister said in his speech, the number of patients in psychiatric hospitals has been falling and that is to be welcomed. There will, however, always be a need for an acute psychiatric hospital. If one examines the figures one finds that there are many admissions but for much shorter periods of time as treatment has become more effective. Rather than having long stay patients rot in a back ward in a large institution, they can now be looked after in an acute sense in hospital and then in a community based way. The community based service will be expensive and there is no shying away from that if it is to be effective. When they closed all the large hospitals in England they found that a number of people who had become accustomed to life in an institution wandered the streets and roads.

I was delighted to hear what the Minister said concerning the Central Mental Hospital as regards insisting that health boards or other services should take some of the patients from that hospital when they no longer require the special services provided there. I will talk to the Minster privately about a case involving a patient who is there because he was declared insane. He has not been insane for about eight or nine years and has been so diagnosed by a number of psychologists, psychiatrists and specialists including the consultant psychiatrist in the hospital. If this man was detained in Great Britain we would all be up in arms about it. However, because he is detained in the Central Mental Hospital there is not a word about it. I am not blaming anyone in particular but that is the way the service was set up and we should try to change it to some degree, if we can.

I am glad to see the commitment the Minister has made to old age psychiatry. We have a huge burgeoning elderly population and an additional £1 million a year will help them. We must look at some way of financing acute nursing home care by some sort of insurance scheme.

With his colleagues in the Department of Finance, the Minister might examine the situation whereby people who pay insurance for years do not get the capital back, just the interest. At the moment insurance companies keep the capital but if that was changed it might be a way of funding some things. Perhaps the Minister for Finance, Deputy McCreevy, might smile on that proposal.

I am also glad to see the Minister's commitment to child and adolescent psychiatric services. Many years ago I was privileged to be the first psychologist from Ireland to attend a Council of Europe medical fellowship to study in-patient treatment for disturbed adolescents. I am glad to say that we now have a number of adolescent units here. There is a very good one in St. John of God Hospital which caters both for private and public patients. It is a highly expensive service which is highly intensive staffwise, but it is a job that needs to be done.

This brings me to the issue of prevention. In planning for the future, the Minister said that a community oriented mental health service is probably the best one. It probably is, but there is always a need for acute care.

One thing I do not agree with, which was mentioned in Planning for the Future, is the provision of additional facilities such as acute psychiatric units attached to general hospitals. I personally think this is a waste of money because one needs a psychiatric team — including a consultant psychiatrist, a psychologist and a social worker — attached to a general hospital, which already exists in a psychiatric hospital. These acute psychiatric units should not be based in general hospitals but should be attached to existing psychiatric hospitals where the expertise already exists, including follow up, planning, social work, psychological and outpatient services. In south County Dublin, for example, why would one attach such a unit to St. Vincent's Hospital when one already exists in the St. John of God Hospital? The same could be said for other areas of Dublin. It is not necessary to duplicate the services that are already there. That would amount to pouring money down the drain.

Quality assurance is an interesting concept and is one we have been tackling within our own services, some of which have an ISO 1000 quality mark. It raises the question of accountability. The day is long gone when health providers cannot be held accountable. They must be accountable for the therapy they provide, whatever that therapy is.

I am glad to see the new mental health legislation arriving but the Minister should consider tackling one or two problems including computerisation. In St. John of God Hospital we have developed probably the most modern computerised system in the world. I say that without fear of contradiction. However, it has brought many legal problems for us concerning the Data Protection Act and the Freedom of Information Act. The Minister should examine this legal minefield if the Act has not been prepared already.

The Minister should also examine the registration of psychotherapists, whether they are clinical psychologists, social workers or trained therapists. There are so many therapists wandering around. People are referred to us who have been to them and they have not been provided with proper care. They have regressed or have been told they were abused when they were children. This might not happen if there was a register of psychotherapists.

Many trained therapists are of very good quality; I am thinking of people in the marriage and family guidance institute and other places. However, there are many people who are not trained. The fact that they have a degree or a particular profession does not mean they are trained.

I would like the Minister to look at the prevention area where more could be done. If one looks at the number of people currently providing stress counselling it shows there is a need for a preventative aspect. That could be done though educational schools and I am glad to see that some of that is happening.

Senator Norris raised the question of locked wards. Unfortunately, these are necessary for the patients' own safety. Frequently when patients are admitted to hospital they are extremely disturbed, otherwise they would not be admitted, and most of them are either frightened or lonely. They are not violent but the locked wards are to protect them from themselves rather than to protect anybody else. Generally, they are moved on, as soon as is practically possible, to a ward that is not locked.

I compliment the work of the religious orders with what used to be called the mentally or physically handicapped. They are now more properly referred to as being educationally disadvantaged. I wish to refer particularly to the work of the Brothers of Charity in St. John of God Hospital and also the work done by St. Michael's House, Stewart's Hospital and many other providers of care for the handicapped.

However, I do not think there will be any need for the provision of that kind of care in future, given the proposals made recently by the Adelaide Hospital to provide abortion in the new Tallaght Hospital, because we will be able to get rid of these people before they arrive in the world. They are planning to redefine the word "unborn" and call it something else. Before eight weeks it will be a foetus, after which it will be an unborn child.

The new legislation the Minister is planning is to be welcomed. The fact that he is hurrying up these reports is to be welcomed also. I would like him to examine some of the matters I raised.

Dr. Henry

I thank the Minister for his contribution and also wish to thank Senators for their interest in this topic. I was certainly not getting at the Minister about the delay in publishing the reports of the Inspector of Mental Hospitals. They are not published much later than any other reports. I was concerned, however, that they should not become historical documents, which is what happens if one does not receive them while there is some perspective and reason for dealing with them. In the early 1980s, despite the Act, the reports were not published at all.

The attitude taken towards some reports in the Houses of the Oireachtas is very serious. If the Minister said he wanted the delay cut by two months this year and four months next year, the report would appear well within the year and we would be talking about relevant topics. In that case people from health boards would not be telling the Minister that it is all right because they have fixed the problem. How do we know?

I like the Minister's idea of publishing a check list and asking people to go through it. I was part of a group that visited mental hospitals and I am not sure we asked the right questions or looked for the right sort of things. I support the Minister's idea of publishing a checklist and encouraging people to go through it.

Senator Fitzpatrick and Senator Lydon, who work within the system, talked about community psychiatry which is an important part of planning for the future. Acute units are, of course, necessary in psychiatric hospitals and/or general hospitals. However, one issue worries me. People appeared to have the idea that community psychiatry would be cheap. That is not true and I am delighted to see both Senators nod their heads in agreement. Community psychiatry is expensive and unless there are multidisciplinary teams, perhaps on a central basis as well, patients are badly shortchanged. Senator Jackman pointed out that there are no social workers on some of the teams. I have a hard suspicion that somebody had a notion that it might be cheaper but it is not. It is much more expensive.

I was delighted to hear Senator Farrell say there was no trouble setting up hostels in his area. Sadly, this has not been the case everywhere. Objections have been made by the most unexpected people to the establishment of day centres or hostels in their areas. It is a difficult problem.

I did not get to discuss the problem of having patients with mental handicap, patients with mental illness and elderly patients in the same institution. These groups have different needs and it is extraordinarily difficult for staff to deal with all of them. The inspector frequently says in his report that elderly patients could be located in community homes and dealt with by general practitioners as they are not in need of psychiatric services. Issues such as this are terribly important.

It is difficult for people who are very isolated to deal with problems within large mental hospitals. I acknowledge Senator Lydon's belief that there is no need for acute units attached to general hospitals. However, his institution is the crème de la crème and there is no criticism of that institution in any of the inspector's reports I have seen. I am glad the Minister did not back down with regard to St. Loman's and insisted that the patients go to the Tallaght Hospital with the first wave. If they did not go then, they would not be there in ten years' time. The Minister was right to insist that it happen.

While I accept that some of the psychiatric hospitals do excellent work in their acute units, the units attached to general hospitals are most important. I wish the Minister luck with the Central Mental Hospital and in trying to get the parent psychiatric units to take home patients who do not need to be in that insitution. I also accept Senator Lydon's point about the fact that "therapists" are not regulated at present. However, that is another issue which is not within the remit of the inspector.

It is also important to note that the inspector does not appear to have much control or influence over the hostels. I am not sure who is in charge of them. I am delighted that the Mental Health Bill is in the Office of the Attorney General. This is real progress and if the Minister can bring it before the Seanad, even if it does not leave the Chamber, we can at least debate it. If the worst comes to the worst he could threaten to use all-island legislation, get hold of the Mental Health (Northern Ireland) Order, 1986, fiddle around with it and say it is part of the peace agreement and must go through the Oireachtas.

I thank the Minister for his interest. If he can put through the personal clothes policy and the identification badges, I will be most grateful. He can warn the staff in his Department that he does not wish to hear this woman mention these topics again.

Acting Chairman (Mr. Dardis)

The Minister indicated he would like to reply. Is that agreed? Agreed.

Mr. Cowen

I am delighted to hear the views of Senators on these and other matters at any time. Members are free to call me to the House on a more regular basis if they wish. I thank the Senators for their contributions. It is a timely discussion, albeit a short one. Much has been said and that is more important than spending a huge amount of time saying nothing.

It is true that, in the context of the Planning for the Future document, there was a great deal of resistance in the community to community based psychiatry. The resistance was based on unfounded misapprehensions about the type of patient who would be reintegrated into society. Thankfully, the number of occasions on which there are objections to health boards buying residences in various parts of the country is decreasing. People can see the policy is a success and that good, high support environments are being created for people who leave institutions for community residences. It is quite proper to remove these patients from institutionalised settings and allow them back into mainstream society. Many of these settings were inappropriate placements in the first place but outdated social realities brought that about initially.

With regard to different groups of people being held in the same institution, whether they are mentally handicapped, elderly, young, male or female, a great deal of progress is being made in organising specific programmes for these groups and providing for interaction where appropriate. We are aware of the need to address that issue. Senator Jackman asked about the future role of the inspector. The new mental health legislation will copperfasten the role of the Inspector of Mental Hospitals. It will continue to be a feature of how we monitor the progress, if any, that is made in the service.

A question was asked about the homeless, people who are inappropriately discharged or people who are appropriately discharged and subsequently fall through the net. An active outreach programme is run by the Eastern Health Board which actively follows up all discharged patients who are in danger of becoming homeless. The programme is specifically geared towards people who could become homeless. I have had reason, by way of Parliamentary Questions, to check this matter in some detail and it is working extremely well.

I do not agree with Senator Lydon with regard to acute units. He spoke about the duplication of services. The current thinking is that psychiatric patients should be integrated in the hospital setting, in the acute sense, in the same way as they would be integrated in the community setting where that is appropriate. It must be borne in mind that many psychogeriatric patients need hospital or acute nursing care to a factor that is three or four times that of people of middle age or younger. Elderly people are more prone to sickness which requires medical intervention. It is, therefore, more efficient to gradually integrate these acute units into general hospitals so people who might require medical care and who happen to be psychiatric patients will have such care as freely available to them as to those who are more mobile and can visit the hospital themselves or call an ambulance.

When one considers Tallaght Hospital and other units which have integrated into general hospitals one can see it is the way to proceed. That does not demean the role of exclusively psychiatric institutions which are providing modern medical care and are constantly refurbishing their capital bases in order to provide the best possible care. Sixteen acute units are now in place, a further ten are planned and, through the new capital programme, I expect to accelerate the rate at which units are coming on stream.

Reference was made to nursing homes. Sometimes psychogeriatric cases are resident in private nursing homes and we have invested almost £7 million in such homes this year to help more older people avail of nursing home care where that is appropriate.

Prevention will be dealt with in terms of the implementation of the suicide task force report which is a long awaited and valuable report. It is also disturbing in that it shows that young males are seven times more likely to commit suicide than young females. The increase in suicides and attempted suicides is clearly a matter of serious concern. The health promotion unit of the Department will be taking an active role in that area. I thank the Senators who participated so constructively in this timely debate and I thank Senator Henry for tabling the motion.

Acting Chairman

The Government amendment to the motion is not moved. Senator Henry has proposed an amendment to the motion.

Amendment No. 1 not moved.

Dr. Henry

I move amendment No. 2:

In the first line to delete "with alarm" and in second line to delete "calls on" and substitute "asks".

Amendment agreed to.

Motion, as amended, agreed to.

Acting Chairman

When is it proposed to sit again?

Dr. Fitzpatrick

Tomorrow at 10.30 a.m.

The Seanad adjourned at 7.35 p.m. until 10.30 a.m. on Thursday, 14 May 1998.