Seanad Éireann díospóireacht -
Wednesday, 15 Dec 1999

Vol. 161 No. 16

Report of the Inspector of Mental Hospitals: Motion.

Mrs. Jackman

I move:

That Seanad Éireann calls on the Minister for Health and Children to indicate the steps he intends taking to tackle the scandalous situation highlighted in successive annual reports of the Inspector of Mental Hospitals.

I am delighted that the Minister is present. It is good to have opportunities to raise matters in Private Members' time because unless we had raised this matter last year and again this year, we may not have had the Mental Health Bill, 1999, as quickly. It may be a coincidence, but perhaps the Minister felt he could not come to the House without having something positive to offer. I am delighted he is present.

Mr. Cowen

I am afraid of the Senator but not that afraid.

Mrs. Jackman

This motion is in response to not just this report of the Inspector of Mental Hospitals but because Senator Henry raised it last year in Private Member's time and I had pleasure in supporting her on the matter. It is a very serious issue. Despite the fact that the Mental Health Bill has been published, it addresses a specific issue but I will keep to the inspector's report.

With regard to the national development plan and the moneys allocated in it, which I raised when we debated it, specific areas are referred to. It will seek to address major unmet needs – I am glad the word "major" is used because they are major – in the provision of modern accommodation for the mentally ill and the physically disabled, to provide facilities for persons with an intellectual disability and to develop a range of facilities for the elderly, because there are elderly people in mental institutions when they should not be, and to provide a comprehensive, quality and accessible acute hospital infrastructure. These elements are all interlinked.

I am sure nobody would disagree if the Minister took the funding from a few kilometres of our national roads and infrastructure, to radically improve the position in mental hospitals. It would go a long way to improve the dire situation described in the inspector's report. That is how I would prioritise the allocation of the pounds, shillings and pence. Infrastructural needs are important but a small part of the infrastructural moneys could eliminate the tremendous problems in hospitals as outlined in the inspector's report.

At Christmas time one thinks of A Christmas Carol, Ebeneezer Scrooge and Dickens. “Dickensian” is the word I would use to describe the conditions highlighted in chapter after chapter, area after area, mental hospital after mental hospital. I would use the word “antediluvian”. The conditions are totally inadequate and unacceptable as we approach the millennium. It is not as if we were raising this for the first time – last year Senator Henry introduced the report of the Inspector of Mental Hospitals for debate. Up to then I do not know if the reports were ever debated. Perhaps that is why we are so horrified because the general public would not have been aware of the issue. They were not aware until Vincent Browne highlighted it in his radio programme and had to give it two weeks of exposure due to the tremendous response he received. Maybe this was due to the anonymity of radio where one can ring in and give an impression of what one sees. One may not feel able to do it otherwise because of the sensitivity and confidentiality associated with mental health problems. He aired this matter very passionately and recently the subject of the psychiatric treatment of prisoners and the Central Mental Hospital cropped up again. We have raised this matter many times in this House on the Order of Business.

What disturbs me most is the fact that mentally ill patients are still the stigmatised Cinderellas of our health system. The reason is that they are voiceless and cannot speak for themselves. Due to the sensitivities I mentioned, their families find it very hard to raise the issue publicly. We rely on the inspector, Dr. Dermot Walsh, through his report to get the Minister's attention and the attention of the health boards throughout the country to alleviate the plight of so many people.

We heralded the patient's charter as a great step forward but, unfortunately, there is not parity of implementation. The mental health sector is one where there should be parity of implementation, because as I pointed out, they are the weakest element of our society, they are voiceless and vulnerable, and they should get the greatest protection and care. This is extremely important. I hope that there are officials in the Department of Health and Children who monitor the patient's charter to ensure it is implemented because it benchmarks the most basic of patients' rights, the rights of those in mental hospitals.

In the short time available I cannot go through the report page by page but I will pick out obvious areas. For instance, plans were mooted to have an acute psychiatric section in Beaumont hospital and this has not happened. I do not know why. What happened to the idea? Is there a problem having a psychiatric service in general hospitals? I had thought, and the inspector suggests it, that it could be an integrated process and that we would not just decide to put our mental health patients away from the general hospitals. I thought that was one of the Minister's objectives.

When Tallaght Hospital opened there seemed to be an unacceptable time lapse addressing this sector and patients were in dreadful conditions in St. Loman's hospital. Why is there such a problem in bringing the psychiatric patients from the dickensian conditions to new hospitals? Perhaps it is an industrial relations issue but, if so, it should be addressed so that patients get the priority they deserve.

With regard to the mid-west region, I compared last year's report to this year's report and I am glad that there are positive signs. Stiofán de Búrca of the health board is in charge of mental health services and I have spoken to one of the psychiatrists, Peter Kirwan, over the past year to find out whether there have been improvements.

Looking at Limerick in particular there were just two areas where money, and money alone, was the problem. The inspector's report states "The only advance since the previous inspection was the transfer of five patients to a community residence at Dooradoyle", which is something we wanted very specifically – moving the patients out to the community, and we are talking about just a handful. The report noted that no progress had been made on the implementation of the Mid-Western Health Board's development plan, which would involve the gradual relocation of mental health services currently on the campus of St. Joseph's hospital, at a capital cost of approximately £5 million. We are still reeling from the billions spent in the budget. A sum of £5 million is a pittance. This facility is available and the goodwill is there, but the money has not been made available.

The second matter about which I am concerned is the provision of bungalows at Lisnagry for patients with an intellectual disability – an issue referred to in the national development plan. There are three bungalows there already. They provide for patients with an intellectual disability and I am glad that although the report states that they have progressed not due to insufficient capital funding, they have progressed. I am not just here to knock – there are positive things that have been done. Further development of the positive elements is needed. There are three bungalows already but if the 36 patients earmarked for the bungalows do not move there soon, some other needy patients will be put there even though they have been earmarked for St. Joseph's hospital. I am aware that the problem was an industrial relations one in that instance. However, such problems should not be allowed to go on and on; they must be addressed instantly to ensure that facilities are available for the people for whom they are intended.

The inspector recommends that capital funding be provided to place long stay patients from St. Joseph's hospital in community residential settings. I know the Minister wants that to happen and I hope it happens as soon as possible. The inspector also recommends that the plans to provide community residences for people with intellectual disabilities in St. Joseph's, Lisnagry, proceed immediately. That can be achieved if the industrial relations problems are resolved.

I want to refer to the response of the Schizophrenia Association of Ireland which Senators received today. The association echoes the inspector's comments and those made in this House recently. The association refers to equity, quality of service and accountability and points to "a devastating lack of will" to apply these basic principles which are part and parcel of a democracy. The association points to the many worrying issues highlighted in the inspector's report about the disturbing lack of attention to patients' rights.

Vincent Browne, on his radio show, highlighted issues in regard to the prescription of medication, the lack of regular reviews and the lack of adequate information provision to patients. The inspector felt that the prescription of drugs in some locations was often arbitrary and was made without regard to appropriate clinical diagnosis.

On the issue of seclusion, it transpired that authorisation was often provided 24 hours after an episode of seclusion commenced. Patients' notes also indicated a lack of medical input relating to specific episodes of seclusion. On the recertification of involuntary temporary patients, the inspector states that where decisions are made to extend the temporary patient reception order or recertify patients, the reasons for doing so should be clearly set out in the patients' case notes. As I read the report, I found that these issues arose across the board in different hospitals in different areas. In some instances, patients were treated in hospital and subsequently discharged without the consultants having made any entries in the case notes. That means there was not any objective evidence that patients had been seen by consultants.

The inspector points out that hospital furniture was found to be dilapidated and shabby, curtains were either missing or falling off the rails, there was a shortage of bedside lockers and screens around beds and there was a lack of privacy for patients, visitors and staff. Reference is also made to the fact that some patients did not have personal clothing. These matters can be addressed without money. What era are we living in when we read such horrific observations?

The inspector raises many other issues, among them the need for the provision of multi-disciplinary teams. I was very saddened to read that of the 900 admissions to St. Brendan's hospital in 1997, 229 patients had no fixed abode. Where were they to go when they were discharged back into the community?

The report is absolutely frightening and it is a cause of shame for all of us that these matters have not been addressed. I appeal to the Minister to accord high priority to this area. I hope we are still a caring nation and that we would look after the needs of the most vulnerable in our society. I do not believe there is a single person in this country who would not forgo an additional kilometre of road, for example, to see priority being accorded to this issue. I hope that next year's report will not contain a single word of indictment of a system which should not be as it is. I ask the Minister to immediately allocate the funding necessary to alleviate unnecessary suffering.

Dr. Henry

I second the motion and thank Fine Gael for tabling it. I am at risk of developing a serious sense of paranoia because I have used my own Private Members' time, which only arises once every 15 months, to debate the previous two reports of the Inspector of Mental Hospitals. I am very disappointed that the Government did not provide time this year for the report to be debated. This is not a party political matter and I fail to see why there was such a reluctance to debate the report in Government time.

I am interested in the amendment tabled by the Government as we are all very pleased to see the publication of the Mental Health Bill. However, the Bill is quite limited and it is difficult to know why it took almost 20 years to produce it. That is not the fault of the current Minister. The Bill deals with the issue of involuntary committal. If the issue had not been dealt with soon, we would have been faced with a very serious situation in the European courts. The Bill also provides for the establishment of a commission to deal with the mental health services and proposes to designate the Inspector of Mental Hospitals as the inspector of mental services. I welcome those measures.

While the report of the Inspector of Mental Hospitals, which is produced on an annual basis, is useful, it is not equivalent to an examination of the entire range of mental services as it does not encompass services provided outside hospitals. It is very worrying that some areas can be de-designated as happened in regard to people with an intellectual incapacity in St. Joseph's unit in St. Ita's Hospital.

I want to concentrate on the substance of the motion which related to the content of the 1998 report. Some improvements have been made over the years and the inspector goes out of his way to point these out. In regard to the situation in Sligo, he states that a great deal has been accomplished in recent years and the service is to be congratulated on increasing community based residential accommodation, reducing in-patient numbers and providing a very attractive mental health centre and day hospital in Markievicz House in Sligo town. If this can happen in an area which, only five years ago, received a terrible report from the inspector, it can happen everywhere. The inspector's comments should encourage people to attempt to upgrade services in their areas.

The report must properly concentrate on the practical workings of the mental hospitals. It is worth noting some areas of improvement but it is astonishing to note the areas in which improvements have not been made. The sharing of personal clothing may seem to be an insignificant issue but it is terribly important to patients not to have to share clothes, including underwear. That is very degrading. The issue is only mentioned twice in this report whereas it was mentioned repeatedly years ago in relation to hospital after hospital. That is a very welcome improvement. However, lockers are not provided for all patients and they are essential, particularly for long-stay patients, who comprise up to 70 per cent of patients in some of our major hospitals. It is important that such patients would have easy access to their belongings.

I am glad to see Senator Glynn in the House because he will have a good deal to say on ward conditions. I was somewhat disappointed recently to hear him call for the disestablishment of the position of the Inspector of Mental Hospitals on the grounds that the inspector's report contained nothing but criticism. The report praises some developments. I am sure the Senator was disappointed to see the report on the hospital in which he works – St. Loman's in Mullingar – in which it was recommended that one ward was in such bad condition that it should be closed down immediately. That is not to cast aspersions on the hospital staff because it must be equally difficult for them to work in these conditions as it is for the patients to live in them. "St. Loman's" seems to be an unfortunate name because the report also states that the conditions in St. Loman's in Palmerstown are appalling. In fact, election literature was found in some of the toilets and since there has not been an election for some time, one can only wonder how long it was since the toilets were cleaned. Like Senator Jackman, I am at a loss to know why patients could not have been transferred to the newly built premises in Tallaght because of an industrial dispute. Patients cannot be kept in terrible conditions while an industrial dispute is resolved.

There are some very depressing examples in the report of how little has changed over the years. Year after year we hear that local management at St. Ita's appears to have very little control over the way maintenance is applied there. This relates to such basic things as gutters not being cleaned, filling up with leaves, and grass growing in the leaves in the gutter so that water pours down inside the building making the walls damp. Surely it can be organised that management is in charge of such maintenance. One sees from reports that this sort of thing occurs all too frequently.

Let me talk about staff. It is very worrying when psychiatrists write to the papers because they feel they are working in conditions which are worse than those in the Third World. Why would they say that? We know the medical profession here does not go in for shroud waving. In today's paper, Vincent Browne, who has done much work in this area, abuses doctors very strongly for not speaking out more about conditions in hospitals. Psychiatrists are put in areas where they, with the rest of the staff, are working in extraordinarily poor conditions. As a member of Comhairle na n-Ospidéal, it worries me very much that so many psychiatric posts are temporary. Why is that? This is not good for morale in the service, it is not good for the people there and it is not good for the patients. Another thing that is important is that a very high level of junior staff who have not much training in psychiatry do a great deal of the front-line work there. This may be important in sections where the inspector criti cises the fact that seclusion orders are put down by juniors frequently, or that prescriptions are not updated often, all very serious areas. The junior staff area must be looked at too, and an increasing number of psychiatrists recommend that frequently.

The nursing area is terrible. Everywhere seems to be at least 20 per cent understaffed, and in some places they are working with staff who have no training in psychiatric illness. This is very serious. I could go on. As regards staff who could help people to become rehabilitated, to go out, there are many people who could live in residential homes in the community in contact with the wider world but there are no step-down facilities for them. The Dublin area is by far the worst. There is a terrible shortage of facilities here. One has to worry if the major psychiatric hospitals in Dublin and Cork, St. Brendan's and Our Lady's, are unloading their long-stay patients into St. Stephen's in Cork and St. Ita's in Dublin because they are hoping to sell their centre city premises for high prices, as I believe is happening.

Let me address the situation in the Central Mental Hospital where there is still slopping out for long-stay psychiatric patients. For years it has been suggested that something should be done about this. It is really appalling and an indictment not of the Minister but of all of us. I remember the new unit there being empty for about ten years while people were deciding what to do with it.

Lack of correlation between psychiatric services in prisons and the Central Mental Hospital is an ongoing disgrace. We know that 25 per cent of prisoners who have been in either the Central Mental Hospital or in psychiatric institutions are going backwards and forwards between them because there are no hospitals for them to go to. Sr. Uí Cuív is the only person I know who is trying to do anything with them. There is a revolving door policy. The Minister for Justice, Equality and Law Reform talks about a revolving door. It is a revolving door between psychiatric hospitals and jails. There are people in our jails who should not be there but they are there because of their psychiatric illness, and we are doing little or nothing about them.

The situation regarding mental illness and homelessness is pointed to by the inspector, which shows how bad it is getting because I have not seen that pointed out before. I do not know how we are going to deal with these people. I have talked frequently about the people I trip over as I go home down Baggot Street at night. Now they are on television and in the newspapers. Between their mental illness and their addiction to alcohol and drugs, they are appallingly difficult people to deal with. However, we must deal with them. When people in the general population say we must deal with them, I ask them to remember this when they refuse permission for day hospitals or community services in their area. I see it repeatedly said "not in my back yard – mental services are to be set up but not in the area in which I live".

Dr. Fitzpatrick

I move amendment No. 1:

To delete all words after "Seanad Éireann" and substitute the following:

"acknowledges the need for improvement in the mental health services as outlined in the Report of the Inspector of Mental Hospitals for 1998; welcomes the publication of the Mental Health Bill, 1999 which will reform existing provisions regarding involuntary detention for psychiatric care and treatment; and commends the Minister for Health and Children for the additional capital and revenue funding allocated to mental health services over the lifetime of the National Development Plan."

I welcome the Minister for Health and Children, Deputy Cowen. He is the first Minister for Health in my lifetime who has taken a sustained interest in mental health and psychiatric services. Everybody in this House knows that mental health is the poor relation of the medical services and has been for many years. A cardiologist appearing on the 9 o'clock news can bring more pressure to bear on the Department of Health and Children with a 15 second sound bite than years of beseeching by patients and relatives and by staff in the psychiatric services.

This year alone an extra £12.2 million is being provided for mental health and priority is being given to forensic psychiatry. As our psychiatric hospitals wind down, as people are moved into the community and there are different concepts of provision of mental health services, the corollary is that our prisons are expanding. We are building more prisons than we have since the foundation of the State.

As well as welcoming the expansion of the forensic psychiatry service, I welcome the expansion of the psychiatry of old age. With an increasing elderly population, the demand for this service is expanding all the time. To be parochial for a moment, I congratulate the Psychiatry for Old Age service on the north side of the city of Dublin. It is providing an excellent service. The waiting time for a consultation is about a week which, given today's medical and hospital services, is astonishing and amazing. I congratulate them.

I welcome the Mental Health Bill as a basis for discussion on a new departure for the development, delivery and overseeing of psychiatric services. I welcome also the Mental Health Commission. This Mental Health Commission is going to have a difficult job. It will have to strike a balance between ensuring openness, transparency and accountability in the delivery of the highest quality of service and preserving patients' rights to confidentiality and dignity in their dealings with psychiatric services. The commission will have to deal also with the problem of a patient who is not in a fit condition to give informed consent. This is a very thorny area. Several speakers have referred already to the lack of case notes in patients' files, especially those in long-stay institutions. This is an area where we will have to upgrade case notes, the quality of reporting and the quality of decision making in treatment planning.

The Mental Health Bill will lead to setting up a mental health commission, a new and badly needed departure in the delivery of psychiatric services. The old system is flawed, slow and cumbersome and, in spite of all the good work by people working in the area, this is not in the best interests of patients. One of the problems I notice in dealing with patients on a day to day basis is the strict demarcation of facilities on the basis of where a patient lives. Where one lives can work against one. For example, as a general practitioner dealing with an orthopaedic problem, I can refer the patient to the orthopaedic surgeon best suited to treating them. I know all the consultants in my area, if not personally then by repute, and I deal with them on a fairly regular basis. As a GP I do not have the freedom to send a psychiatric patient to the consultant I feel is best suited to treat their problem. There is a demarcation, which I am sure exists throughout the city and the country, which does not work in the best interests of patients. A patient on one side of the street has to attend one hospital while a patient on the other side must attend another hospital. In this day and age this is not good enough. The system is driven by bureaucracy and administration, not by patients' needs, and it must change.

The commission will have to face the fundamental problem of vested interests working throughout the health services, not just the mental health services, whose only wish is to maintain the status quo as that is the easiest way for them to continue and does not disturb them or the people they represent. The fact that it might not be in the best interests of patients suffering from mental problems is neither here nor there in their book.

I do not intend debating the forthcoming mental health legislation but we will have to deal with difficult questions and find answers. For example, section 7 of the Bill says that those with personality disorders and people who are socially deviant or mentally handicapped will not be part of the remit of the Bill. From my experience, as I am sure everybody in the House will know, these people suffer and can develop psychiatric problems. One of the problems I have noticed over the past 30 years is that the psychiatric services are not prepared, or do not want, to appear to deal with these problems. They want to put them to one side and have them dealt with by specialists. There is a good reason specialists should deal with these problems, but it should be within the remit of the mental health commission.

Finally, Senator Henry spoke about hospitals and the appalling conditions in some of them. I think this is down to the management of hospitals and that we cannot put the full blame on the Department of Health and Children. I use the analogy of hospitals and hotels, although it should not be taken too far. Managers of hospitals and hotels have one thing in common, namely, to ensure service is delivered to their customers – and that means patients in the case of hospitals. I have never seen a hospital manger dine on hospital food, check the hospital toilets or stand behind reception dealing with customers. In a hotel one pays only once for the service provided, but in hospitals a person could be paying twice or three times through taxes, VHI and cash deductions for services rendered.

The problem with the health services, and I refer mainly to the psychiatric services, is that there exists too much of the poor law mentality in our attitude towards their delivery. For this reason I welcome the mental health commission because if it is given power, money and teeth, it can, for a modest financial outlay, change the concept and standards of mental health care in hospitals and, as Senator Henry said, in prisons. We should not confine its remit to designated mental health services as mentioned in the Bill. Rather we should ensure the commission has an input into psychiatric training, continuing education and can check the bona fides of persons or organisations purporting to improve mental health.

Mr. O'Dowd

I welcome the Minister to the House. Like Senator Henry, I wish to say that it is with regret that we have to use Private Members' time to discuss an area of health care which is of increasing importance. I acknowledge the work done by Vincent Browne in bringing the issue of mental health and the associated services to public attention, including my attention. In his programmes and articles he puts his finger on the button and makes us sit up and take action on this very important issue.

I welcome the Bill which the Minister published yesterday. Clearly, it is not a matter for debate tonight, but I welcome the important provisions contained in it and the significant progress being made in mental health services in general. Over the past number of years a very significant shift has taken place in the population of hospitals and an increasing number of people, quite properly, are moving into the community, being restored to health and to where they always lived. There is also a positive policy of placing people in the community, either in sheltered accommodation or under very low supervision, and of welcoming back to the community people who are and will continue to get better and, please God, return to full health and to where they always lived.

We have to compare this progress with the dickensian conditions which are still clearly present in a number of our psychiatric hospitals. The report of the inspector is excellent. It is thorough and goes through each institution, making very significant comments. I would like to address the comments on quality care issues raised in the report which are very important. The report states:

The importance of patients' rights across a broad range of issues was stressed and the responsibility of mental health services in such matters was highlighted. It is both ethically correct and clinically desirable that newly admitted hospital patients are examined, reviewed and assessed by senior medical staff within 24 hours of admission.

This seems a very fundamental procedure but it does not happen, perhaps due to pressure on people working in the system. I acknowledge the tremendous work done by all the medical, nursing and caring staff in our hospitals. Nevertheless it is a matter of great concern to read that the inspectorate felt drug prescribing in some locations is often arbitrary and made without regard to appropriate clinical diagnosis. The number of patients, particularly long stay patients, who are on numerous drugs simultaneously, often at high dosages, was striking. In some instances the prescriptions have not been reviewed for some considerable time. It is important to review medication at frequent intervals. There appeared to be an increasing number of sudden deaths in psychiatric hospitals, some of which were attributed to drug related effects. I was shocked to read this and hope the Minister will immediately instruct health boards and all the people who work in psychiatric hospitals to take critical note of what is contained in the report and ensure that by the time of the next report these issues are clearly dealt with and significantly removed from our attention. It is very important to bring these matters to public attention.

I was shocked and thought I was reading a document from the last century by the description of St. Mary's Hospital, Mayo, where–

Much of the accommodation for patients was provided in large institutional rooms that combined sleeping accommodation, dining space, day facilities and a nurses' station all in one area. For most of these patients there was little to stimulate or interest them. They had their final meal at 4.30 in the afternoon and some were in bed by 5 p.m. to accommodate the nursing roster. Concern was expressed at the fact that there were two patients in bed in the day area who were dying and this space was shared by fellow patients from the same ward. This situation was unacceptable.

This is utterly unacceptable. I spoke to the chief inspector having read the report and he told me that situation will not arise again. In fairness I spoke to the psychiatrist who works for the hospital who pointed out an alternative view, namely, that those people were dying with their family, that is, the people with whom they had lived for many years. To them this was their home and this was the context in which it should be viewed. I am deeply concerned by all these issues and feel they must be tackled in a clear and succinct manner.

The Government and the Opposition want to go forward together. We all want to change the system and to make it better. Fine Gael will insist that it is made better and that more care, time and attention is paid to the mental health issues which affect thousands of our population. I pay tribute to the people who help to look after mental health patients in the community, particularly those who are here tonight. We will ensure that this issue is kept at the top of the health agenda until the radical changes which are urgently needed are made.

Minister for Health and Children (Mr. Cowen)

I commend Senator O'Dowd and other speakers on their contribution. Did Senator O'Dowd's party show the same commitment in Government which it is now showing in Opposition? We need to improve the mental health services and the amendment acknowledges that. Under the national development plan we will provide the resources which were not provided by previous Administrations.

I have listened carefully to the contributions to this debate and I fully recognise the need to improve standards in our mental health service. The Inspector of Mental Hospitals plays a crucial role in providing an independent and detailed analysis of our mental health services. On the publication of the report for 1998 I was the first to acknowledge that much needs to be done to develop the quality of our services. I also stated that I intended to facilitate health boards in bringing about the improvements and developments identified by the inspector.

The Framework Document, The Psychiatric Services – Planning for the Future, which has been the cornerstone of the policy of successive Governments over the past 15 years, developed the concept of a comprehensive psychiatric service located in the community close to where people live and work. It was envisaged that this would replace the centralised and largely institutional services which were planned at a time when modern treatment methods were not available. The policy outlined in that document is still valid today. The problem lies in the rate of progress in providing the alternative facilities it recommended.

Notwithstanding the shortcomings identified in the inspector's report, there have been many improvements in mental health services, which have been outlined in successive annual reports of the inspector. These relate particularly to the increase in the number of acute psychiatric units associated with general hospitals. In 1983, prior to the publication of The Psychiatric Services – Planning for the Future, there were ten such units in place. This has now increased to 17. Approximately one third of all psychiatric admissions in 1998 went through these units. The number of community residences in 1983 was 111 with less than 1,000 places. In 1998 this had increased to 386 with almost 3,000 places. In the same period the number of in-patients has reduced from approximately 13,000 to 5,000.

The challenge now facing the health services is to provide all our in-patients with an alternative to care in large psychiatric institutions. Unfortunately, the rate of progress in providing this alternative service has fallen behind. It must be acknowledged that the mental health services have frequently lost out to other services which have been given priority in the allocation of development funding.

It is time to make a concerted effort to tackle in a determined and comprehensive manner the problems in our mental health services which have been so clearly highlighted in the inspector's reports and in this evening's debate. As a first step, I have allocated an additional £12.2 million revenue funding to the mental health service for next year. This represents an increase of over 100 per cent on the additional funding provided in 1999.

The lack of multidisciplinary teams in many areas of the mental health services has been highlighted by the Inspector of Mental Hospitals in his report. Some £2.9 million has been allocated towards the further development of community based mental health services, including the improvement of psychology and social work services. Extra funding is being allocated to the health boards in 2000 for the recruitment of additional paramedical staff to address this issue. The precise numbers of additional staff will be worked out in discussions with the health boards early in the new year.

An additional £1.1 million has been allocated to further developments in child and adolescent psychiatry services. This funding will provide for the appointment of additional consultants in child and adolescent psychiatry and for the development of multidisciplinary teams to focus on specific areas, such as attention deficit hyperactivity disorder.

The increase in the number of people living to advanced old age requires the development of specialist mental health services to meet their specific needs. Old age psychiatry services have been expanding in recent years and an additional £1 million is being allocated in 2000 to further this development. The details will be discussed further with the health boards early in the new year.

In his report for 1998 the Inspector of Mental Hospitals referred to the fact that some patients in psychiatric hospitals have been in institutional care for many years and recommended the establishment of dedicated teams to plan their reintegration into the community. Some £0.25 million is being allocated to the Western Health Board to fund such a specialist-led team which will commence a rehabilitation programme for long-stay patients in St. Brigid's Hospital, Ballinasloe. If this pilot project is successful, a similar approach will be considered for other hospitals.

Some £1.35 million is being provided to facilitate substantial improvements in the forensic psychiatry services in Dublin, Cork and Limerick. These teams will liaise with the Director of Prison Medical Services and the Department of Justice, Equality and Law Reform regarding the provision of appropriate psychiatric services in our prisons. They will also assist in the management of disturbed behaviour within the health board mental health services. An additional £1 million has been allocated towards suicide prevention programmes and £2.5 million has been provided towards the implementation of the new Mental Health Bill which I circulated yesterday.

The provision of capital funding is essential if the mental health services are to be transformed in the way we would wish. I have ensured that substantial capital funding under the national development plan will go towards the development of mental health facilities. Over £140 million capital will be provided over the lifetime of the plan for the service. A significant part of this funding will go towards the development of acute psychiatric units linked to general hospitals as a replacement of services previously provided in psychiatric hospitals.

In addition to the 17 acute units already in place, a number of units are currently at various stages of development including the Mercy Hospital, Cork; Beaumont Hospital, Dublin, which I intend to announce in the next few days; St. Vincent's Hospital, Elm Park; James Connolly Memorial Hospital; Ennis General Hospital; St. Luke's Hospital, Kilkenny; Portiuncula Hospital, Ballinasloe and at Nenagh, Portlaoise, Castlebar and Sligo General Hospitals. A further four acute psychiatric units are under consideration as part of the national development plan at Dundalk, Wexford, Mallow and Mullingar. At the end of the period of the national development plan, it is the intention to have the programme of acute psychiatric units completed, which will mean there will be no further acute admissions to the old psychiatric hospitals. The plan will also provide for more community facilities, such as mental health centres and community residences, which will accelerate the phasing out of the old institutions.

It is worth noting that many of the points raised in the inspector's report relate to clinical and administrative issues associated with the provision of care. I expect them to be addressed by the relevant professional and management staff in the health boards and hospitals concerned. To assist service providers in attaining excellence in care delivery, the inspectorate prepared guidelines on good clinical practice and quality assurance in mental health services. The guidelines are based on a checklist used on inspections embracing the main issues relating to the satisfactory clinical and administrative practice. The document sets down a series of desirable and achievable standards of care both in relation to the physical structure in which care is delivered and the clinical and other issues connected with the provision of care.

The guidelines are seen by the inspectorate as an educational endeavour to increase awareness of the main quality issues in service delivery and their monitoring, refinement and improvement. I arranged to have the guidelines published and circulated to mental health professionals and service providers in the country. The Inspector of Mental Hospitals is currently paying particular attention, when carrying out inspections, to the extent to which the procedures recommended in the guidelines are followed.

In September of this year I made a commitment to publish new mental health legislation before the end of the current session. Yesterday I fulfilled that promise with the publication of the Mental Health Bill, 1999. This Bill will significantly reform existing legislation concerning the involuntary detention of persons for psychiatric care and treatment.

In many respects the Bill I have published goes further than the proposals originally envisaged in the White Paper on mental health legislation. This is particularly the case in so far as the rights of detained patients are concerned. I noticed that Senator Henry regards it as a small Bill. It contains 73 sections and deals with protection of patients' rights, something I regard as a priority in the context of a legislative response to transform and modernise mental health services. Provision is made in the Bill for an automatic, independent review of each decision to detain a person for psychiatric care and treatment within 28 days of their detention. Reviews will be carried out by mental health tribunals consisting of a consultant psychiatrist and a legal assessor and operating under the aegis of the mental health commission. The review will focus on two issues, whether the person concerned is mentally disordered and whether the correct procedures were carried out in detaining them. A tribunal will be empowered to order the release of a patient if it considers that he or she does not require to be detained involuntarily.

Some commentators have referred to the fact that the White Paper proposed a review of detention after seven days and have suggested that what is contained in the Bill published yesterday offers less protection to involuntary patients than was promised in 1995. That is incorrect. The White Paper proposed that a procedural review of the legality of a person's detention would take place within seven days of involuntary detention. The type of review envisaged then would have been a paper exercise which simply checked that all the correct procedures had been carried out. It would not have touched at all on the crucial question which must arise in all cases of involuntary detention – whether the person is mentally disordered to the extent that it warrants a restriction on his or her liberty. The White Paper did not consider that the type of fundamental, clinical review which I am proposing was necessary until a person had been detained continuously for over a year. Therefore, my proposals represent a major advance on those put forward in the 1995 White Paper. I hope the columnists take note.

The new Mental Health Bill will also have major implications for the role of the inspector. Under its provisions, the existing office of the Inspector of Mental Hospitals will be replaced with the office of the inspector of mental health services. The inspector will be employed by the mental health commission, also established under the terms of the Bill, and will thus have complete independence from the Minister and from his or her Department. This represents a major improvement, in my view, on the proposal in the White Paper that the office of the inspector be associated with the Department of Health and Children.

In addition to the annual inspections of in-patient facilities which are carried out at present, the new Bill will require the inspector to carry out an annual review of all mental health services. The inspector's review of the services, including reports of inspections carried out, will be published along with the mental health commission's annual report.

Another important new role for the inspector will be the regulation of standards in the mental health services. A register of approved centres, in which each hospital or in-patient facility providing psychiatric care and treatment must be registered, will be maintained by the mental health commission. Regulations will be made specifying the standards to be maintained in all approved centres, including requirements in relation to food and accommodation, care and welfare of patients, suitability of staff and the keeping of records. The execution and enforcement of these regulations will be the responsibility of the inspector of mental health services.

I thank Senators for providing the opportunity to debate the content of the reports of the Inspector of Mental Hospitals and the mental health services generally. The initiatives which I have outlined will, I hope, reassure Senators that mental health services are not being neglected by this Government and that the service shortcomings identified by the inspector are being addressed.

Mr. Quinn

I appreciate the Minister coming to the House. I recognise the task he faces and the task the State as a whole faces in this area.

I would not have read this report if I was not a Member of this House. Like many citizens, I would have been unaware of the publication of the report. Most Departments attempt to publish damning reports like this in a clandestine manner. It says a great deal that to have this debate we had to wait until Private Members' time at 6 p.m. on a Wednesday evening. The Minister and the Department have a case to answer for that alone.

Senator Henry has been seeking a debate on this for a year. It was not until recently that I read the report and it shocked me. I felt as I did when I read the visitors' report on Mountjoy Prison. It opened a world which was new to me, one which I did not know existed. Once this world emerges, we must reject it as unacceptable. Even in the understated style used in the report, the picture it reveals is terrifying. I urge everyone to read this report.

I hope this debate will be the first step on the way to dealing with mental health in a way which is fitting in a rich, modern society, not one that seems to be dealing with it as Charles Dickens would have done a century ago. We have often heard the comment that democracy is best judged by how it looks after its minorities. If mental health patients are a minority, we stand indicted. I am grateful to the Fine Gael Party for devoting its Private Members' time to this subject. There is no party political gain to be made from it but the party took it because Senator Henry drew attention to it and the Fine Gael Members have given us the time to debate it.

I do not blame this Minister any more than I blame the previous three Ministers. There have been Fianna Fáil, Fine Gael and Labour Ministers and they all stand indicted for what has happened. Minister after Minister has dodged the issue. Why did they do that? They preside over a Department in which there is a culture of denial. No Department is better at running away from problems or trying to sweep them under the carpet than the Department of Health and Children.

None of these crises is a one-off; they are connected. There is a culture of denial, aided and abetted in this case by the medical profession, which has sold the past at the expense of its patients. The reason for that is the relentless pressure caused by the minimal resources we have devoted to the problem.

Inspector Dermot Walsh has done a great job in this report. He details the over-prescription of drugs as a solution to the problem. It is part of a strategy of patient care. Any psychiatrist will tell you that drugs are the route to follow whenever there is a problem and nothing else can be done. That is the challenge we face. The starving of resources to address the whole problem of mental health has been ongoing on an annual basis and it has allowed this unacceptable problem to accelerate.

The solution of seclusion and restraint, as detailed in the report, entails the use of straitjackets and padded cells. I had not heard this terminology for some time. I am pleased, therefore, that this scandal has become public. Like other citizens I accept responsibility for what happened, although like them I was unaware of the practices described in the report.

Recent Ministers, the Department and many psychiatrists in the mental health area have a case to answer. However, we will never get to grips with this problem unless we deal with the real culprits. The Department is not alone in fostering a culture of denial. It has been able to indulge it only because a similar culture is prevalent throughout society – we are all guilty.

The uncomfortable truth is that many people do not want to know about mental health. It has traditionally been regarded as a taboo subject, to be kept out of sight and ignored in the same way as TB and cancer in the past. Nevertheless, because we have been able to drag our taboos into the open one by one we are in a position to tackle the problem outlined here. We are just as guilty as any Minister in turning a blind eye.

A small step towards a resolution would be to enact comprehensive mental health legislation. I hope the Bill published yesterday will fulfil that requirement. Senator Henry has demanded it for some time. Enacting it will be a demonstration of our determination to ensure that the problem is fully addressed.

Senator Henry said the new Bill is small in content but large in scope. The Minister referred to expenditure of £140 million over five years. That is just over £20 million per year. In a recent budget the Government allocated £20 million to Croke Park. I am not critical of that, but it puts expenditure in this area in context.

If we are to solve the problems outlined here we must do so with determination. That is the challenge we face. I welcome this debate and the publication of the new Bill. We must ensure that as a nation we meet the challenge before us.

Miss Quill

I read sections of this report last Saturday afternoon, having finished reading a review in The Irish Times of the book written by Mary Raftery and Eoin O'Sullivan, which is based on the subject matter of the television programme “States of Fear”. The experience filled me with sadness and disgust that we as a nation were able to tolerate for so long the treatment meted out to orphans in orphanages and patients in mental hospitals without seeking to find out what was happening. If some of the outrage at the budget had been exercised against the practices and malpractices in the treatment of patients in mental hospitals in the past we might not have to read the lurid details contained in this up-to-date report.

It is about time we as a nation honestly examined our conscience. How is it that we lock people away and sweep their problems under the carpet? When I grew up in the 1950s we treated in the same way unfortunate women who happened to find themselves pregnant and could not find a husband. Much happened in this country in my time that I hope we will not take into the new century.

I was very encouraged by the Minister's speech and by the promise of new legislation to replace the Mental Treatment Act, 1945. It is not before time. Our understanding of psychiatry and the development of psychiatry as a science has moved on dramatically since the 1945 Act. It is time our laws responded to the knowledge at our disposal.

The new legislation is welcome and it will be discussed in detail in this House. The Minister outlined some of its provisions. When it is enacted we will have put in place a modern legislative system to underpin different practices, codes of practice and provisions which will differ from those prevailing today. Given the Minister's remarks, I am more optimistic than I was this morning.

Legislation alone will not be enough. There must be a dramatic shift in the attitude of the public and the practitioners who treat psychiatric patients. A dramatic shift in our cultural approach to the manner in which we treat them is required because if the public demands a high standard of care based on best practice it will be forthcoming. That will only occur when debates like this happen more frequently and when the public is given a better insight into the way in which patients with mental disorder were catered for in the past by the public services. It will then demand that a different approach is taken.

The inspector draws attention to the nature of quality care, which appears to have been remarkably absent in far too many instances. I hope that is a feature of the past. To that end we not only require new legislation but a total change in attitude to the provision of care. That will demand a very high standard from the professionals.

The role of the inspector will be substantially changed in the context of the impending legislation. That is also important. An inspector should arrive unannounced to make an inspection. It is not good enough that notice of his arrival is circulated. When I was a teacher we washed behind our ears when we were told of an inspector's visit. It is most important that a system be put in place which allows for the arrival of an inspector at any time without notice.

When I read in Mary Raftery's book the description of a visit by a Department of Education inspector to an orphanage in the midlands and the glowing report he wrote, it sent shivers down the back of my neck. He wrote a glowing report about the care that was being given to the children and lyrically described the heroism of the people who were dealing with orphans in such a humane and compassionate way. It has since transpired that this was one of the institutions where orphans were treated with extraordinary brutality. The Minister, to his credit, has opened the departmental archives and we have been able to see the inspector's report. It is important that inspectors arrive unannounced and at any time.

There is a connection between homelessness and the closing down of the big and bad old institutions. They had to be closed and they were not closed soon enough. I am glad that they will all be phased out. However, unless there is a consequent follow through and proper provision at community level, people who have been institutionalised for years will be worse off if they are allowed out into the community without the necessary support services. It is critical that we put proper community based services in place to cater for the needs of people who have been in mental hospitals.

I am glad that provision will be made for teenagers. A number of young people are being discarded by our education system but there is no proper psychiatric provision for teenagers. I am glad that this is to be catered for.

It is very important that the House debates the report of the inspector annually. That is the only way we can establish for ourselves whether there has been an improvement.

Mr. Ryan

I spent a cathartic half hour denouncing the Government this morning during the debate on the Appropriation Bill and I wish to be more constructive this evening. A fundamental issue of resources is involved and our society must make a fundamental choice about the allocation of resources and whether we should allocate them to the public or private sector. I do not wish to dwell on the question of allocating resources because it would be wrong to pretend that the condition of our psychiatric hospitals is the fault of a particular Government. It is the fault of Irish society, as Senator Henry said earlier. I could take issue with the present priorities of the Government but that would be a short-term criticism. There is a long-term issue to address.

Mental health services have always been the easiest area in which to make financial cut backs. At a meeting during the height of the health cuts in the 1980s, I heard someone say that a person who needs cardiac surgery will be happy to appear on a platform and declare that he cannot get the necessary surgery because of health cuts. Someone who needs to be admitted to hospital for acute schizophrenia will probably not be able to demand it and, if he is able, will be profoundly reluctant to do so. Ministers for Health do not deliberately take advantage of that reality but there is a process of prioritising which means that when they get around to spending on the psychiatric services there is no money left.

For my own benefit, I did a spreadsheet showing the change in expenditure on the health services between 1989 and 1999. The overall percentage increase was 144 per cent which means that expenditure more than doubled. Expenditure on general hospitals increased by slightly more, by 147 per cent. Expenditure under the title, Psychiatric Programme – Diagnosis, Care and Prevention of Psychiatric Illness, in the same period increased by 69.98 per cent – half the rate of the health services, overall. That is fair comment.

The Minister's figures raise a question about gaps in our service. He said that in 1983 there were 1,000 places in the community and 13,000 in-patients. Now, there are 3,000 in the community and 5,000 in-patients. I am very glad that many of those who used to be in-patients are no longer. I am also concerned that many of those who used to be in-patients are now living on the streets. I am very concerned that we would continue a programme at a time when we have increasing needs.

In case I forget to do so I should declare an interest. My wife is a consultant psychiatrist. I say this in case there might be a conflict of interest, although if there is to be a conflict it will be between me and my wife when she reads what I have to say.

Dr. Fitzpatrick

She can read the Official Report.

Mr. Ryan

She has far more sense than to read the Official Report of Seanad Éireann.

The fact that our ageing population will put increasing demands on our service has been mentioned. Senators have also mentioned the suicide problem. I am reluctant to use the term "suicide crisis" but there is an increasing incidence of suicide in our society. The World Health Organisation has identified depression as the second biggest illness which the world community will have to worry about in the next century. There is a debate in the psychiatric services on whether what the WHO calls depression really is so. However, we must recognise the fact.

I do not wish to list any of the horrific details in the inspector's report. I assume these conditions will be corrected very quickly and that no Government will allow such conditions to continue. Perhaps that is a generous assumption, but I assume from what the Minster has said that we are going to see an end to leaking roofs, the absence of privacy, inadequate toilets, poor food and all the other things that are complained about. However, that is not nearly enough.

I was glad to hear the Minister say that regulations, which I assume will have the force of law, will be made specifying the standards to be maintained in all improved centres, including requirements in relation to food, accommodation, care and welfare of patients, suitability of staff and the keeping of records and that the enforcement and execution of these will be the responsibility of the inspector. This gives the inspector considerably greater powers than he used to have. Previously, he simply had the power to report. He will now have an enforcement role and one which I hope he will be encouraged to play by the Department of Health and Children. It is extremely important that he should do so.

I disagree with Senator Glynn that the position of Inspector of Mental Hospitals should be abolished. The Minister's proposal to give the inspector real powers is the correct one. These reports have slowly but surely galvanised Irish society with regard to what is happening in our psychiatric hospitals.

Beyond what is in the report in terms of physical conditions, we need fundamental changes in services. The inspector mentions the need for paramedics, occupational therapists, social workers and so on. There is a need to make it clear that doctors who are employed in the public health service should make the public health service their priority and the priority of their time. The public health service is not the banker on which one builds one's private practice. It is the priority. That priority should mean that somebody who is paid up to £90,000 per year to work 33 hours should work those hours and that ancillary services, such as offices, secretaries and so forth, would work exclusively in the public health area and not provide a State subsidised support for the private practice.

It should also mean that where outpatient clinics are held, only where it is medically appropriate would anybody other than a consultant psychiatrist see somebody in that clinic. I am not of the opinion that in every case a consultant must see the patient because some of the patients might be returning for a routine appointment. However, it should be part of the contract that the only situation in which a patient should not be seen by a consultant psychiatrist is where it is medically appropriate. Inconvenience, holidays and other commitments are no reason for people not doing their job.

The buildings will be sorted out in the next couple of years and the issue of staff training is being tackled. After that we will be obliged to sort out the quality, intensity and continuity of medical care for psychiatric patients.

Mr. Finneran

I thank the Opposition for affording Members the opportunity to debate the mental treatment legislation and the report of the Inspector of Mental Hospitals. As Fianna Fáil spokesman for Health in the Seanad during the last Administration, I did not let a week pass without calling on the then Minister for Health to bring forward this legislation. On that basis I compliment the Minister, Deputy Cowen, on his initiative in this regard. His predecessors, even though they were regularly called upon to do so, did not respond positively and put off bringing the legislation forward. Indeed many of the comments which emanated from previous Ministers were concerned with civil liberty considerations. That issue should not have been to the fore and I am pleased that, after so long, somebody has the courage and has taken on the responsibility to update 60 year old legislation.

The Mental Treatment Act, 1945, is out of tune with what practitioners in the health services consider appropriate treatment. It can safely be said that professionals in the service have been acting outside the law for many years. If the provisions of the 1945 Act had been strictly implemented in the past 20 years, many people in the nursing and medical profession would have been deemed to be in breach of the law because they were implementing a more liberal approach than that laid down in legislation.

Seventeen years ago a document titled Planning for the Future which dealt with the psychiatric service was published. It was an important document which appeared to contain a recipe for the future of the psychiatric service. However, there was a major omission. Nobody thought it worth their while to resource the plan and everybody knows what happens to the best of plans if they are not given financial resources – they become aspirations. It was implemented in piece meal fashion and the customers of the service, the psychiatric patients, were the victims of a plan that was never resourced and was being implemented under 60 year old legislation. That is the context in which we have been dealing with the psychiatric service in recent years.

I know the current Inspector for Mental Hospitals and I knew his predecessor. I worked in the health service for many years and I have a keen interest in the area. I am pleased he has identified so many problems in the mental hospitals. In the year before the arrival of the third millennium it is amazing that an Inspector of Mental Hospitals would be obliged to report on matters such as the gutters on a building not working or a radiator being out of place or there being no door in a shower room. Where was the local manager of the hospital, the local clerk of works and the hospital administrator? These people must have had responsibility for the maintenance of their buildings. If they did not have responsibility or did not have the resources, they had a responsibility to highlight that and ensure it was dealt with.

Health boards have responsibility and should take some blame in this area. Over the years members of health boards, health board executives and the administrative sections geared themselves towards the pressure area of high-tech medicine and forgot the psychiatric service because there was nobody there to speak up for it. Yesterday was an important day with the publication of the legislation and today is equally important in that we are debating the inspector's report in the context of that legislation.

There are 73 sections in the Bill and they cover a wide range of important issues. The most important is patients' rights and these are given extensive coverage. We have heard about farmers' charters and patients' rights but nothing has been heard about the rights and protection of psychiatric patients. In fact, rather than a supportive environment, in recent years there was a reduction in the number of people being trained in that area. Non-professionals and people with no training were working in the psychiatric service to an inappropriate extent.

The fact that catchment areas are sacrosanct is a major concern. My colleague, Senator Fitzpatrick, already referred to this issue. It is inappropriate that somebody who goes to their general practitioner and wishes to be treated within the psychiatric service has no choice as to who will treat them. They must go to the psychiatrist in the district mental hospital or the unit in their area. If I have a sore thumb or need to have a toenail removed, I can choose where I will go to have the procedure carried out. I have a statutory right to have it done in the Mater Hospital in Dublin or in Castlebar, Galway or elsewhere. Why does a psychiatric patient have a lesser right than a patient in the general service? Patients' rights are vitally important.

It is generally accepted that people who were discharged from mental hospitals were not provided with alternative accommodation and proper services. Having been left without support, many of them ended up in prison. That is a sad outcome. I hope the new legislation will ensure there is a full psychiatric service attached to the Prison Service. Look at what has happened in America and other jurisdictions and at the level of suicide, injury and trauma in prisons which do not have psychiatric services. That is a message for us. It should be an important part of the new legislation that we do not forget there are people in other situations and in the charge of other Departments who are in need of psychiatric care. The education system provides a full service in prisons. Is it not as important that we ensure the health of those in prison is protected?

One of the psychiatric services in the Western Health Board area has been closed in recent years. I am glad to see the Minister has provided £250,000 for a pilot scheme to extend the rehabilitation of another. The day of the large mental hospitals is gone and they are no longer needed, but alternatives to them are needed. Funds and resources must be part and parcel of the new legislation. Planning for the future was a recipe for disaster because it was not funded. This is good legislation and, while I hope there will be amendments to it as it goes through both Houses, I hope there will be a definite decision to resource it.

Mr. Glynn

It is unfair to say that the Leader of the House denied a debate on this issue. He said it was possible to have this debate in tandem with the new Mental Health Bill. I welcome the Bill. Many promised it but the Minister for Health and Children, Deputy Cowen, delivered it.

I will take up where Senator Finneran left off in discussing the planning for the future of the psychiatric services. I recall that the programme manager of the Midland Health Board said he would never allow the mistake made in Great Britain, when a similar situation obtained there, to be repeated here. When community services were brought on stream, hospitals were run down. However, this is what has happened here and my worst fears have been realised.

If one examines the statistics for the number of residents in psychiatric hospitals at present – statistics referred to throughout the report of the Inspector of Mental Hospitals – it is noticeable that too many people who administer the planning for the future of the psychiatric services are preoccupied with the numbers now in psychiatric hospitals. As Senator Finneran rightly said, the resources were not provided to devolve the service into the community. Patients were discharged into the community but resources were not provided for them. I say that as someone who worked in that service for a number of years.

There was a motion before the House about the unavailability of acute psychiatric beds in the Eastern Health Board area. An interesting study was conducted on bed occupancy, or inappropriate bed occupancy, in the Eastern Health Board area. It is interesting to note that the report of the Inspector of Mental Hospitals states that, in the Laois-Offaly catchment area, 54 persons were lodged overnight in St. Fintan's but were not formally admitted to the service and, in the Longford-Westmeath catchment area, 109 patients were lodged overnight in the hospital but were not formally admitted. The reason for this is because they sought bed and breakfast. They had nowhere to go. The acute services in our psychiatric hospitals are used not for hospital purposes but as a hostel for people who have nowhere else to go. That is a scandalous outrage and a gross abuse of an acute service.

Senators Ryan and Henry commented on a remark I made on the Order of Business pertaining to this report that the position of the inspectorate should be abolished. I restate that and I will say why. In the context of the devolution of acute psychiatric services, large hospitals were not built to treat modern psychiatric illnesses or patients, rather they were built as asylums to keep people in. My belief, which is shared by many who work in the psychiatric services, is that the inspectorate should be an inspectorate of hospital services. I made the comment before the publication of this legislation and I am satisfied an inspectorate of health services would suffice. If we are spending time and money in devolving services to a multidisciplinary arrangement at general hospitals – something I warmly welcome – an inspectorate should not exist which focuses on something belonging to a bygone era.

Reference was made to reporting. There is no excuse for bad reporting by either medical or nursing personnel. Paper and pens are plentiful and everyone who works in the psychiatric services, both in the medical and nursing disciplines, is well able to write. A comment was made about medical charts being signed. If memory serves me correctly, one would have to be a midge to sign in the space provided on medical charts. A new design of medical chart would be appropriate. Reference was also made to patients wearing their own clothes. That is an important matter and I am pleased that in the hospital where I worked nursing staff accompanied patients to purchase their clothes. That is how it should be and it is welcome.

One group have not been mentioned are the relatives of some of the forgotten people. Senator Quinn spoke about why some people found themselves in psychiatric hospitals. Far too often, patients in such hospitals are not visited by their relatives. If they are, it is on an infrequent basis. When patients pass to their eternal reward, I regret to say that the first question asked is whether they left any money.

Senator Henry touched on an important point when she referred to staffing. When the schools of nursing in the various hospitals were closed in the early 1980s, it cut off the lifeblood of what was prior to that a reasonably well served service. I can only speak for my health board, and St. Fintan's and St. Loman's hospitals had two marvellous schools of nursing. It is some time since either had a student but, thankfully, that will change. I have been calling for a college of nursing in the Midland Health Board area for 14 years and the only one who heard my call was the Minister, Deputy Cowen. Last Thursday, he formally launched the school. It is fully operational and students are attending it at present.

With regard to support services, I wish to record my appreciation of the Mental Health Association and also the members of the Society of St. Vincent de Paul who visit residents in psychiatric hospitals who have no one to visit them, or if they do, who will not come.

Successive speakers said ad nauseam that psychiatry is a discipline in its own right. As Senator Quinn said, it is the first to be attacked when resources are scarce. Senator Finneran put his finger on it. There is no excuse for grass growing in gutters, water flowing down walls and broken doors. The inspector also referred to a lack of curtains and screens. There is a case to be answered. Many of the decisions taken in the 1980s by successive Ministers on foot of that famous document, “Planning for the Future”, were cost driven and it was the psychiatric services that got the chop.

I thank Vincent Browne. Some local newspaper reports in County Westmeath were less than favourable. I feel sorry for those who have nowhere else to go. I also feel sorry for the nursing and medical staff who do their best in adverse conditions. St. Finian's ward has been mentioned. It was decided deliberately not to provide the necessary finance to upgrade it as a decision had already been made to close it. I rest my case.

Mrs. Jackman

Because of the sensitivity of the issue the debate in a sense has been muted. As a consequence I will not be too hard on the Minister. Suffice to say I hope we will not debate the next report and find nothing has been done. What Vincent Browne said on his radio programme and in his newspaper column obviously caught the imagination of the nation. People were shocked. I am concerned however that when some other issue is highlighted it will take precedence.

Those who contributed to the debate – I thank them for supporting me – were shocked when they read the report. They found its contents hard to believe. What concerns me however is that successive Ministers would have been aware of them. Even though we are all aware of the vulnerability of the people concerned – they are voiceless and silent – the amount provided is minimal in terms of the sum required.

I have been raising the issue of attention deficit hyperactivity disorder – ADHD – for the last two years and this is first occasion on which I have received a response from the Minister. The report produced for the Joint Committee on Health and Children at my request has yet to be debated in the Dáil or Seanad. A sum of £1.1 million is to be allocated to fund further developments in child and adolescent psychiatry services which will provide for the appointment of additional consultants and the development of multi-disciplinary teams to focus on specific areas, including ADHD. However, this sum would not solve the problems being experienced in the Mid-Western Health Board region.

Parents of children suffering from ADHD have to voluntarily fund assessment in the United Kingdom. The amounts spent by health boards abroad because of the failure to provide services here were listed in a recent edition of the Sunday Independent. Parents know from the age of one and a half to two years that the reason their child is lively is not that he or she is hyperactive but that he or she is suffering from a disorder. They spend their time trying to convince their general practitioner of this and are sent from one psychiatrist and psychologist to another knowing instinctively that something can be done for their child. Because the disorder remains undetected, some of these children end up in prison. The Minister's response is therefore inadequate.

Teenagers suffering from depression are still being treated side by side with adults in ward 5B of Limerick Regional Hospital. This is unacceptable as they are unable to cope in such conditions for weeks at a time. The inspector recommended that appropriate provision be made for the development of child and adolescent and later life psychiatry services. He stated that in Limerick there was no separate unit for child and adolescent in-patients and that a priority for the service should be the provision of a dedicated regional unit for the child and adolescent service. It is shocking that we are unable to focus on teenagers who present with depression and give them the privacy they need. This would not cost a fortune but the inspector's recommendation has been ignored.

The director of the Central Mental Hospital, Dr. Smith, said that at least 100 prisoners from Mountjoy should be in a psychiatric institution and not in prison. What kind of society is this? These are the issues that should be debated as they are the underbelly of a successful society. It is up to us to spread the word that funding should be provided immediately.

The Minister said he would prefer the inspector to be employed by the mental health commission established under the terms of the Bill. In this way he or she would have complete independence from the Minister and the Department. I admire Dr. Dermot Walsh for being so open. From where would the funding come? It comes down to a question of pounds, shillings and pence. There is not one Senator who would begrudge additional funding to deal once and for all with the problems in our psychiatric services so harrowingly outlined today. I hope that words such as "dickensian", "horrific", "harrowing" and "antediluvian" will not be used next year in responding to the needs of the weakest in our society.

Amendment put.

Tá

Bonner, Enda.Callanan, Peter.Cassidy, Donie.Chambers, Frank.Cox, Margaret.Cregan, John.Dardis, John.Farrell, Willie.Finneran, Michael.Fitzgerald, Tom.Fitzpatrick, Dermot.Gibbons, Jim.Glynn, Camillus.Keogh, Helen.

Kett, Tony.Kiely, Daniel.Kiely, Rory.Lanigan, Mick.Leonard, Ann.Lydon, Don.Mooney, Paschal.Moylan, Pat.O'Brien, Francis.O'Donovan, Denis.Ormonde, Ann.Quill, Máirín.Walsh, Jim.

Níl

Burke, Paddy.Coghlan, Paul.Coogan, Fintan.Cosgrave, Liam T.Doyle, Joe.Henry, Mary.Jackman, Mary.McDonagh, Jarlath.

Manning, Maurice.O'Dowd, Fergus.O'Toole, Joe.Quinn, Feargal.Ross, Shane.Ryan, Brendan.Taylor-Quinn, Madeleine.

Tellers: Tá, Senators T. Fitzgerald and Keogh; Níl, Senators Burke and J.Doyle.

Amendment declared carried.

Question put: “That the motion, as amended, be agreed to.”

Tá

Bonner, Enda.Callanan, Peter.Cassidy, Donie.Chambers, Frank.Cox, Margaret.Cregan, John.Dardis, John.Farrell, Willie.Finneran, Michael.Fitzgerald, Tom.Fitzpatrick, Dermot.Gibbons, Jim.Glynn, Camillus.Keogh, Helen.

Kett, Tony.Kiely, Daniel.Kiely, Rory.Lanigan, Mick.Leonard, Ann.Lydon, Don.Mooney, Paschal.Moylan, Pat.O'Brien, Francis.O'Donovan, Denis.Ormonde, Ann.Quill, Máirín.Walsh, Jim.

Níl

Burke, Paddy.Coogan, Fintan.Cosgrave, Liam T.Doyle, Joe.Henry, Mary.Jackman, Mary.McDonagh, Jarlath.

Manning, Maurice.O'Dowd, Fergus.O'Toole, Joe.Quinn, Feargal.Ross, Shane.Ryan, Brendan.Taylor-Quinn, Madeleine.

Tellers: Tá, Senators T. Fitzgerald and Keogh; Níl, Senators O'Toole and Ross.

Essential Repairs15December1999.

Grant

Question declared carried.

An Cathaoirleach

When is it proposed to sit again?

Mr. Cassidy

In addition to the joint sitting of both Houses at 12 noon in the Dáil Chamber tomorrow, the Seanad will sit at 2.30 p.m. tomorrow.