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Seanad Éireann díospóireacht -
Wednesday, 20 Jun 2018

Vol. 258 No. 12

Mental Healthcare in South-East Region: Statements

Gabhaim buíochas leis an gCathaoirleach Gníomhach as ucht an deis labhairt ar an ábhar seo tráthnóna inniu. I welcome the opportunity to discuss mental health services for children and adolescents. The promotion of positive mental health and well-being is important to us all and each of us, politicians, administrators and clinicians, have a role to play in this work. While I remain as open as ever to constructive criticism and realistic suggestions, I ask that objectivity and, above all, the best interests of service users are paramount in our debate today.

The pending resignation of three psychiatrists in the south-east region is the main issue before the House this evening. Yesterday, I met national and local HSE representatives who assured me that they are exploring every possible option to ensure that the vacancies in the south east's CAMHS are filled and to ensure continuity of service. I will be meeting them again on 3 July where they will provide me with a progress report.

Notwithstanding the global lack of availability of mental health specialists, the HSE is currently conducting an extensive advertising campaign to fill these vacancies. In order to provide immediate cover, it has established weekend consultant paediatric psychiatry clinics in Waterford by availing of support from Galway-based consultants. In addition, the HSE has been in contact with other CHO areas and with agencies both abroad and in the private sector to look for locum cover.

I wish to strongly restate the Government’s commitment to mental health. This is reflected in the allocation of an additional €200 million for mental health services since 2012. While this amount is significant by any standard I will continue to press for further resources annually in line with the Programme for a Partnership Government commitments.

The HSE 2018 service plan commits to further development of CAMHS. This is against a background where the demand for CAMHS has increased by 26% between 2012 and 2017. Approximately 18,800 referrals are expected for HSE CAMHS this year alone. To meet this demand, we have increased the supply of services. We have approved more than 2,000 new mental health posts since 2012. We now have 69 CAMHS teams and three paediatric liaison teams supported by about 75 CAMHS beds nationally. Further beds are planned to come on stream as quickly as possible. In addition, we have funded an extra 140 psychiatric nurse undergraduate places each year.

The recent appointment by the HSE of approximately 114 assistant psychologists and 20 psychologists will help to develop counselling services in primary care. Thirteen assistant psychologist posts have been introduced in CHO 5, which includes Waterford and Wexford. It is anticipated that these posts will deal with the less complex child and adolescent cases thereby reducing the demand on CAMHS.

A key focus for me is continued investment in innovative digital technologies to support access to prevention and early intervention services. I have examined IT initiatives in other countries and I believe that we can use these technologies in Ireland. The HSE has established a working group to progress a national telephone and text helpline and digital information supports for those requiring access to services. It is my intention that the roll-out of the new telephone helpline will commence before the end of this year. I have also requested the HSE to pilot a project providing remote access to counselling services in the primary care setting.

There is a broad range of initiatives under way or planned across mental health. I believe that these initiatives will help us to deal with the increased demand for mental health services. I look forward to a constructive and collaborative discussion.

Dr. John Hillery recently resigned as a consultant psychiatrist in the HSE after nearly 30 years working in mental health and intellectual disability services. He was not due retire from his post until 2022. He did so in protest over the treatment of staff and patients within the State’s mental health services.

Last week Dr. Kieran Moore, a specialist consultant paediatric psychiatrist, told the Oireachtas Joint Committee on the Future of Mental Health Care that he and two of his colleagues from the south-east region were resigning because they were concerned about working in unsafe conditions. Dr. Moore said that he was resigning because it is untenable and unsafe and that two of his colleagues were doing the same. He said patients were coming into a building that is in a state and where staff are burnt out. He said mental health services required continual funding and looking after the people who look after patients.

The prevalence of those suffering from mental health problems was increasing, he said, describing the issue as "a national emergency".

Unless the psychiatrists are replaced, there will be no services for children in Wexford and Waterford and it is scandalous that children in this region face the prospect of having no public consultant psychiatric services from next month. I refer to an important point my party colleague Deputy James Browne raised in this regard and, perhaps, the Minister of State can provide some clarity. It is Deputy Browne’s understanding that all other CAMHS staff who have been working under the psychiatrists such as psychologists and occupational therapists can no longer effectively do their jobs because they have no one to oversee them. Will he confirm that this is the case? Where does this leave them? Will the other CAMHS staff be relocated? Will they be allowed to continue without a psychiatric consultant to oversee them?

According to the Irish Hospital Consultants' Association, of the 44 consultant psychiatrist posts advertised in 2015 and 2016, practically a quarter had no applicants and 30% had only one applicant. Sixteen consultant psychiatrist posts advertised for interview in 2016, including posts in child and adolescent psychiatry, learning disabilities, forensic psychiatry, general adult psychiatry, and psychiatry of old age, received no applicants whatsoever. These competitions with no applicants were for posts in Sligo-Leitrim, Cavan-Monaghan, Cork, Carlow-Kilkenny, Donegal, Longford-Westmeath, Laois-Offaly, and Waterford-Wexford and the Central Mental Hospital. This problem is not confined to the south east but the services there are in dire straits. I acknowledge what the Minister of State said about support from Galway-based consultants. However, the position in Galway is not much better and, therefore, this is only a stopgap measure.

According to recent figures provided to Fianna Fáil, 6,181 children were waiting for a primary care psychology appointment at the end of January 2018. Of the young people waiting, some 1,635 of them have been waiting more than a year to be seen. This means these children spent all of 2017 waiting for an appointment.

I have made several suggestions over the past year. I try to be practical and solution-driven. The proposal for a 24-hour helpline that is accessible to GPs for vulnerable children and teenagers who hit a crisis in mental health should be considered. In that case, a GP can pick up the phone and access CAMHS in an emergency. Such a service would not be abused and it would mean unnecessary referrals to emergency departments would be avoided. In a crisis, when young kids and teenagers are vulnerable, emergency departments are not the correct place for them to present themselves for assessment and I ask the Minister of State to take this on board. I have had people in my surgery in the middle of a mental health crisis when the help they require is immediate and urgent. They are vulnerable and it is shameful to then tell them they must wait more than a year for an appointment.

I hope the Minister of State will take this on board and I look forward to working with him on this issue.

I thank the Minister of State for coming to the House. I know it is not easy and I must say fair play to him because every time there is a difficult situation, whether it is on television or here, the Minister of State never baulks from being present and I appreciate that.

I will remind the Minister of State that he and I went to the south east area, CHO5 in Wexford. We visited Slaney House and saw the conditions that day. In the following days, the Minister of State made a promise that the conditions in the house would change and that the staff would be helped. It is now eight months later, and nothing has happened. The Department wrote to us and to the staff in Slaney House and said that that a building was available but that they expected the staff to share a building with another organisation, which was most inappropriate because of the lack of confidentiality for children and parents.

I will not dwell on that and, instead, address the issues that the Minister of State raised. I am distressed that the Minister of State has been handed a script that not only glosses over the issues but once again contains misinformation and nonsense. Our committee can identify the nonsense and I will go through some of this now. His script contained a paragraph which referred to constructive criticism and asked for objectivity. I am sorry, but we are being objective. We are also talking about reality.

On the pending resignation of the three psychiatrists, the Minister of State said that everybody is exploring possibilities and the HSE will report back to him by 3 July. I would love to know what will be in that report and I can almost predict its contents. The Minister of State said there will be an extensive advertising campaign to replace the three psychiatrists. Does this refer to the sole advertisement in the Sunday Independent two weeks ago? Is that the extensive advertising campaign? The Minister of State said that he would get support from the Galway-based consultants. That is like asking the over-burdened CAMHS in Galway, which is coping well, to share the south east's workload. He is asking one or two consultant psychiatrists to travel to the south east and deal with the problems there. None of that makes sense.

Once again we were told of the allocation of an additional €200 million for mental health services since 2012. The day that we know how CAMHS is spending these millions, we will be able to tell the Minister of State that he is right, and that funding is terrific. Until that day comes, and we know the truth about how that is being spent, we cannot speak about the budget. Yesterday, we were told that more administration staff are employed than nurses. Dr. Kieran Moore said there are five managers managing four staff in the south east. How can departmental officials speak about their plans when they cannot even take into account what is happening in the south east and throughout the country? The south east is not unusual; this is happening everywhere. The reference to beds is waffle to satisfy anyone who does not know what mental health services are about.

The Minister of State mentioned 114 assistant psychologists and how 13 of those will be in Wexford and Waterford. How can they? There can be no teams unless a consultant psychiatrist leads them. They might as well twiddle their thumbs.

We were told about innovative digital technologies. Where are we with that? This country is well advanced technologically, with the exception of the HSE. I wonder whether this is on purpose. Is that so that there is no accountability and the executive can use the excuse that it does not have the correct software?

The Minister of State referred to yet another working group to progress a national telephone, text and helpline and digital information. When children have an enduring illness, when they are in the middle of psychosis or when they are running down the streets or jumping out of a window, no helpline will work. How many millions of euro has the Department spent on putting helplines in place because they are safe and easy? What about the advertising tag line, "Let someone know", that the Department keeps talking about? Who in God’s name is the child or parent to "let know"? There is nobody around to help.

Today, I chaired the Joint Committee on Future of Mental Health.

The representatives of the Mental Health Commission attended the meeting. I asked them who their boss was. They investigate the various child and adolescent mental health services, CAMHS, and so on but to whom do they report? They report to the Minister and the Department of Health. Is there not a conflict of interest there, given that the commission is funded by the Department of Health? Is everybody just minding one another and keeping everything secretive?

I ask the Minister of State to address the issues we originally examined last October. He should not believe what he is being fed and I cannot emphasise that enough.

I welcome the opportunity to contribute to the debate on this matter, which is impacting citizens and patients in my area of the south east. I welcome the Minister of State, Deputy Jim Daly. As previous speakers said, he is always prepared to face up to his responsibilities as a Minister. Unfortunately, I have to agree with other speakers with regard to the unacceptable situation that has developed in mental health services in the south east and the manner in which the HSE allowed the service to reach a crisis point.

The HSE must be held accountable. It was my understanding that with the development of the new pillars, especially with A Vision for Change and the establishment of the mental health pillar, the director of mental health services and the hospital boards, there would be more accountability in terms of how the HSE is managing and deploying resources from the funding the Government is putting in place. We all agree that mental health services have always been the Cinderella of the health service in this country. I acknowledge the efforts the Minister of State and the Government are making to address that in terms of investment and reform. However, it is unacceptable that vulnerable patients, particularly children, who require immediate and urgent intervention or professional support are being let down by the health services and the HSE, which is charged with managing the services. I urge the Minister of State to call in the relevant managers and those responsible in the HSE.

The Minister of State outlined the immediate temporary measures that have been put in place to respond to the crisis in mental health services in the south east. There is a temporary deployment of consultant psychiatrists from Galway to the south east in order that the specialist teams in CAMHS can continue to operate. I commend those specialists. I have met the specialist nurses, occupational therapists, psychologists and others who work under the consultant psychiatrist and they are overburdened with work. They need additional supports to allow them to make interventions when they are required. This is not just about money. It is about accountability and reform in our health service. We will have to crack the nut some day and I hope the Minister of State, Deputy Jim Daly, and the Minister, Deputy Harris, will do that and hold the HSE to account in order that it delivers the service it is charged with delivering for the citizen.

I have had reason to visit the CAMHS in Waterford, and I am aware that the Wexford situation is especially challenging. The services have successful outcomes for the people who access them. I have spoken to families who have managed to do that. They acknowledge the service and support they get and commend the staff. However, it is so sad to see resignations taking place and people being overburdened due to a lack of resources or services. We must approach this in a different way. For some reason, the HSE always allows matters to develop into a crisis when there should be red flags and alarm signals long before that. We had an excellent debate in the House on mental health services only a year ago, when we brought specialists in from all sectors to outline the challenges that face mental health services.

I believe the Minister of State is doing his best, but we must do more. We need to haul in the people who are often faceless. They are not the psychologists, psychiatrists or the occupational therapists who are at the coalface. They are the managers. The ratio of managers to front-line staff in the HSE is simply wrong. We need to get to the bottom of why this situation is occurring. I commend the Minister of State on his efforts and I will support him in trying to reform the health services. I will support him in the forthcoming budget where he will be fighting for additional funding to invest in mental health services. We do not wish to see this issue arising again either in the south east or in any other part of the country. The Minister of State must haul in the people in the HSE and hold them to account. In addition, the hospital boards are supposed to be overseeing the operational efficiency of the HSE. If that system is to operate as intended, those boards must also haul in those who are responsible.

Ultimately, we must support the people on the front line and the vulnerable patients who need access to services. We can talk as much as we wish in the Seanad, the Dáil or anywhere else but we must reform the system to deliver services where they are most needed. The Minister of State referred to new technology, digital access and information technology. We must utilise those technologies. Four new primary care centres have been built in my constituency. One is in Waterford city in the grounds of St. Otteran's Hospital, a former mental health institution. The other three are in Dungarvan, Tramore and Carrick-on-Suir. They are new, state-of-the-art buildings which have the facilities and capacity for outreach mental health services. We must get the professionals who are delivering the service on board and reform the system by putting the front-line resources in place, away from the management, and utilising all the resources available, be they buildings, IT or professional human resources. I will work with the Minister of State to achieve that but I urge him to keep his focus, and that of the HSE, on resolving the issues in the south east and providing what is so badly needed there at present.

Cuirim fáilte arís roimh an Aire Stáit. Unfortunately, the debate this evening will not be on positivity because we do not have that in this country. I will give the facts to the Minister of State. I have a key question for him and I implore him to respond to it. I will outline the key indicators regarding mental health services in the south-east region and across the State and I ask him to say how he will react to them. I have been monitoring the situation closely since last year, both in the Committee on the Future of Mental Health Care along with my colleague, Senator Freeman, and through parliamentary questions. This is my area of expertise, as it is for Senator Freeman. It is our niche and our passion. It is extremely important.

The time for rhetoric is over. If we do not act today, there will be another catastrophic abuse of human health on this island. In fact, it has already happened. Earlier today the Ombudsman for Children and the Mental Health Commission agreed that mental health services have already collapsed. I would need to consult a thesaurus to find what out what other words can be used after "crisis" and "emergency" because it has gone beyond those. We stand here and make grand speeches about the state of our mental health services, but I am tired of doing that. We do it once a week and then go away and wait for another story to break in the media. The Minister of State must outline exactly what the Department is doing to address this chaos. Otherwise this is a waste of time.

Dr. Moore, the specialist consultant paediatric psychiatrist in County Wexford, said there were supposed to be 30 clinicians working in the greater Wexford region, but just five and a half of the posts are filled. That is no surprise to the Minister of State. In December 2017 the CHO 5 area was the worst performing in the State and was at only 48% of the recommended levels in A Vision for Change. What did the Minister of State do between December and now to address the shortfall? I ask him to give specifics. He knew about the state of the services and he had time to begin to address them.

His response to the effect that we will take the staff from Galway amounts to robbing Peter to pay Paul and is simply not good enough. Dr. Moore said there were no inpatient beds in Wexford and that when he needs a child to go to hospital, he fills out a form and faxes it with his fingers crossed in the hope of finding a bed. In the vast majority of cases children do not get beds and they never get them urgently.

Ms Margaret Brennan from south Wexford appeared before the Joint Committee on the Future of Mental Health Care. She is fighting for her children. During the discussion on the resignations the question was asked by the Chairman: "What now?" Ms Brennan said there is nowhere to go and that there is nothing there for her or families like hers.

The Department of Health glossy advertising campaigns claim that mental health is as important as physical health, but the actions are indicative of a different attitude. The 2012 mental health budget was 5.6% of the HSE budget, while this year it is 6.3%, a tiny proportion. The lack of investment is actually promoting stigma and is actively keeping mental health services on their knees.

I call on the Minister of State to address the details I have set out about his Department. It was extremely difficult to obtain some of the information. For example, a couple of weeks ago I asked for a simple breakdown of child and adolescent mental health services budgets. I was told that the HSE does not have that information. Yet, I know that variants of that information were given to the Joint Committee on the Future of Mental Health Care. The Minister of State may wish to keep the conversation around mental health as void as possible, but I will not let him do that because it would be a disservice to the 30 plus years I spent working in the services. I want the Minister of State to commit now to improving with urgency the record-keeping of the mental health division.

I attended a staff engagement group in the HSE yesterday morning. The group was made up of 60 or 70 ordinary staff, including porters, psychologists, staff nurses, GPs and other doctors. I am concerned about the impact of the negativity of the mental health services and – I will try to remain polite – the greed at the top layer of the HSE. They are terrified. When Tusla social worker staff left in their droves, they would not tell people that they had worked for Tusla because they were getting abuse in the pub and cinema and when they went out for meals. They held their heads in shame. I do not want that to happen to our wonderful HSE staff.

We have an opportunity for the director general of the HSE to be appointed. We do not want anyone helicoptered in, which is what happened in the past. We want experts, not only with managerial expertise but with clinical caring expertise. We want the interview panel to represent the voices of patients. It should comprise people with expertise who can judge whether a candidate is fit to run a caring health service in the country. How can anyone expect to finance an overhaul of the mental health division when millions of euro are being thrown to private profiteers? The Minister should note that the agency spend for the first three months this year alone was a little under €13 million in three months. That represents almost the entire increase of €15 million we were celebrating last year in the budget.

The Minister of State has failed. We have failed as legislators and as caring individuals in attempting to allow our children to live happy lives. We have failed in our responsibility for mental well-being in this country. We need to roll up our sleeves. I do not know how we do that because I am getting hoarse from asking for it again and again.

This is another real life and death issue for young people of the south east. I thank the Minister of State for coming into the House this evening. This debate is due to my intervention on the Order of Business in the Seanad last week. I took the view that it was necessary due to the details that emerged from the Oireachtas Joint Committee on the Future of Mental Health Care, of which Senator Freeman is Chairman.

The committee revealed that three consultant psychiatrists in the south east were handing in their resignations and due to finish up in mid-July. I was shocked and alarmed to hear that. The committee and subsequent media reports set out how these resignations pose a serious risk to the immediate provision of mental health care in the south east and demonstrate that the situation there is close to a state of emergency.

I will outline the problem as I see it. There may have been disparate reasons for the resignation of these particular consultants, but, as alluded to by others, Dr. Kieran Moore was clear in his contributions to the committee. He said that his resignation and that of others was due to the continually declining conditions in mental health services in the region. After 16 years of providing a service in Wexford, he had finally had enough. For the good of his patients and his community he went public. He claims that the service should have 30 clinicians but has only 5.5 staff currently available. The buildings those people work in are not at all suitable. Community healthcare organisation 5, incorporating Carlow, Kilkenny, south Tipperary, Waterford and Wexford, seems to be the political orphan. It cannot get appointments or business cases taken up and acted upon by Tusla and HSE management.

Dr. Moore's indictment of conditions was reinforced by the resignation from the HSE of the widely respected President of the College of Psychiatrists of Ireland, Dr. John Hillery, in February. He told the Family Carers Ireland conference on Monday last that his early resignation was in reaction to the HSE's failure to deal with major staffing problems. He blamed the Government for failing to increase the mental health budget, despite recommendations from A Vision for Change more than a decade ago. He declared that doctors were faced with the moral distress of not being able to access the resources needed to help their patients. We have seen over the past year that such distress is particularly acute in the south east.

Now is not the time to discuss the ongoing emergency in emergency cardiac care provision in Waterford and the surrounding counties, but the issue is relevant in the light of a larger denial of adequate health provision in the south east. This is especially the case since University Hospital Waterford lost its regional hospital status.

To add to the personal testimonies of Dr. Hillery and Dr. Moore, today we received the latest report from the Ombudsman for Children on the experience of young people of mental health care in Ireland. The report does not make for happy reading. I trust the House will indulge me if I quote certain extracts from the report. The report reminds us that Article 24 of the UN Convention on the Rights of the Child recognises the right of children to "the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health". Article 24 further provides that state parties to the UNCRC, like Ireland, must "strive to ensure that no child is deprived of his or her right of access to such healthcare services". The World Health Organization definition of health is quoted as a "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".

How far we are from that vision currently? Today I met and talked to student representatives from the Union of Students in Ireland and Waterford Institute of Technology, including Celine Casey, who is the WIT students' union welfare officer. She outlined how of the 482 cases she had dealt with this year, more than 400 had some mental health aspect while almost 300 were primarily mental health related.

Ireland has one of the highest levels of chronic depression and anxiety in the EU, at 12.1% of the population. The narrative about asking for help is now well established. What is not is the access to the actual help that people are meant to seek. That any young person is left on a waiting list for more than a year is appalling, but that 2,500 children have been left waiting over a year for a psychiatric appointment is a national disgrace.

A total of 209 children below the age of 18 have been waiting more than a year for an appointment with a psychologist in County Wexford, a full 10% of the national figure, despite the fact that Wexford makes up just 3% of the national population. Why are Wexford's children singled out for this cruelty? Mental health made up 13% of the health budget in 1984; in 2017, it was down to 6%, a staggering decline in the face of rising problems. We are here discussing the specific situation in the south east, and that there is a regional disparity in mental health delivery was sadly proved last year with the housing of young people in adult care units in the area. We know that other regions of the country do not face the same pressures, despite the national level of crisis. The Minister of State has talked today and previously about the fact that these and other vacant posts are now being advertised, but I want the Minister of State to tell me a number of things. What emergency provision is the Government making for the delivery of mental health services in the south east when the three resigning consultants' notice periods come up in mid-July? Hiring their replacements will take a long time.

I know my time is up. I have some more comments to make and I will reply to the Minister of State's own reply. There are a number of issues even in the Minister of State's statement that just do not add up. He talks about the Galway psychiatric-----

The Senator is over a minute over time.

However, he is only talking about weekends. What about Monday to Friday? There are so many holes in what he has said, and I hope we will have enough time to discuss them further here.

As there are no further speakers, I ask the Minister of State to respond. He has a maximum of eight minutes because we must conclude by 7.50 p.m.

I thank all Senators for the time, energy and commitment they continue to give to this area and for their contributions. I will dispense with my prepared script and try to answer some of the questions they have asked as best I can and address some of the points they have raised.

Senator Swanick asked a question about the CAMHS staff in Wexford and Waterford and whether they can still do their jobs. He said Deputy Browne has mentioned this. The reality, as the Senator knows, is that there is a CAMHS team in each of the areas. It is not just one consultant psychiatrist; there are teams of varying numbers, ideally 13, although not all of them can achieve that. There are occupational therapists, OTs, speech and language therapists, psychologists etc., on the teams. This is what we are talking about when we look to other areas. We wish to get consultant psychiatrists from other areas to provide the necessary clinical governance for these teams to continue. How do we do this? A very obvious way is telepsychiatry, whereby a consultant psychiatrist can clinically govern the team's work peer to peer on screen in order that the team continues its work.

Senator Grace O'Sullivan asked me a question about weekend clinics. They are being offered to young people on Saturdays and Sundays. Some consultant psychiatrists very generously work weekends from other areas to provide cover here. They can also provide clinical governance cover from Monday to Friday. Of course this is not ideal and we do not want to be in this space.

There is the issue of three people having resigned at the same time. One, Dr. Moore, has spoken about the conditions in which he worked, which is his right and entitlement. I have no difficulty with that whatsoever. I have only been in this job for a year but I have met Dr. Moore several times. As Senator Freeman said, I was in Wexford, where he worked, 12 months ago, and he asked me about the building and the facilities. As I understand it, the new facilities in Wexford will be open in six weeks' time to allow the team to move in, in order that they do not have to continue in the present situation. I do not say this defensively; I say it as a matter of fact. Dr. Moore has raised other issues. He talked about it taking an hour to fill out the paperwork involved in admitting a young person to a CAMHS unit. Of course it takes an hour to fill out that paperwork. That is the least time it should take. One is admitting a child to an inpatient unit. Should Dr. Moore be doing all that? I would take issue with that. A consultant psychiatrist should be doing exactly what a consultant psychiatrist should be doing. There should be step-down models of administering a consultant psychiatrist's work to ensure he or she is not overburdened with paperwork. This is the space we need to be in. These are the conversations we need to have.

We need to look at how we do what we do to change our direction. We can beat up the HSE about the lack of consultant psychiatrists all day long, but whether one considers the NHS or the position in Australia, New Zealand, Canada or the United States, there is a worldwide shortage of consultant psychiatrists. There are just not enough of them, and this will not be fixed overnight. Therefore, we need to look at new ways of administering what consultant psychiatrists do. We need to look at what they do in New York, for example. I saw recently that they have physicians' assistants who open up the body on the operating table, the surgeon comes in and does the procedure and the physician's assistant does the closing up. Here the surgeon opens up the body, does the procedure and closes up the body. There are better ways of using consultants' time.

The online space offers enormous potential. I have seen telepsychiatry in operation in other countries. If one considers an example in which a child presents with psychosis overnight in an emergency department, ED, he or she would be far better off if there were an online consultant psychiatrist available to carry out the assessment. In fact, many children are much more comfortable dealing with screens now because of the lifestyle we have evolved into and it has been proven that children on the autism spectrum react to screens better than to real life. What this says about the way we are raising children is another debate. Were this facility available in emergency departments, there would be 24-hour cover, as opposed to patients having to wait for seven hours in an accident and emergency department for a consultant psychiatrist to come on duty at 9 a.m. the next morning, which is far from perfect. It is about how we do what we do.

Three consultant psychiatrists have resigned at the same time. One had an issue with conditions; the other two had very different reasons for leaving. One, as I understand, is moving on to do a fellowship, which is their entitlement and their right, and intends to return to work in the area but wants to improve their learning, which is any consultant's right. In fact, we should be encouraging that. The third consultant was delivered through a locum agency and has now informed that agency that they are no longer available to work for it. I do not know why. It is not my business why people do this. It is very unfortunate that the three resignations have come at the same time. This has been presented by many in language to the effect that this is "a crisis" and that everything has "collapsed". Our challenge now is to recruit consultant psychiatrists into the Waterford-Wexford area. If some of us wish to keep shouting and roaring about it as "a crisis", "calamity", "chaos", all these words-----

It is a crisis.

I did not interrupt the Senator. It is deeply irresponsible of us to do that. The challenge we all collectively face now is to recruit three consultants into the area. How can we do this? We will not do it by destroying the image of the services and tearing up the work that has been done over the years. Last year, CAMHS delivered services to 14,400 young people. It is a vital service and it is vital we get it right and protect it. Of course things are going wrong, of course there are people not getting the services they seek or require, but that happens in every single discipline. We do not throw the baby out with the bath water. Let us have a degree of responsibility towards where we are going. The comments on the issue of the three resignations are not correct. Dr. Hillery has retired, not resigned. There is a very big difference. It is his entitlement to do so. I believe he is interested in running for a career in the job we do. He is entitled to do so, and I wish him every good luck with that. I have already referred to the recruitment of psychiatrists as being a challenge. As there is a worldwide shortage, we will have to look at the work they do and the standard procedures under which they operate in order that we make better use of their time. Online delivery of telepsychiatry offers consultants the opportunity to work from home, which suits an awful lot of consultant psychiatrists, who would be more than happy to do more work from home rather than having to travel an hour and a half from one location to another and an hour and a half back, which is three hours on the road in a given day. We need to look much better at how we do what we do.

Senator Swanick has a very good suggestion, to which I have heard him refer previously, about 24-hour access for GPs to be able to consult with consultant psychiatrists, who could give them advice on how to deal with patients presenting with psychosis and other such issues, which are very challenging for doctors trained as GPs. The Senator's suggestion is particularly good and has as much validity, if not more, today as when I heard it from him the last time.

Senator Freeman talked about the building in Wexford. I think I have dealt with the issue of responsibility towards the future. The Senator referred to the helpline. A 24-hour helpline is not what I have been talking about since I have had this job. I have been talking about introducing a single point of access for everyone who has a mental health issue or for a friend who wants to refer someone. That is the phone line to which I am referring. This can be done through text, online or by phone, but it is important we have one single point of access and that one is appropriately referred once one makes a call in order that I can ring this one number and say my friend is acting strangely or is very down and I will be told there is a Jigsaw or whatever other service in my area. We cannot all be wonderful experts on the services, whether ALONE, Aware, Pieta House, Jigsaw, CAMHS or whatever other service.

I have already spoken about the language of "collapsed" and "crisis" and "struggled with", and Senator Devine struggled with other words to describe the situation. I do not think that is helpful.

I have addressed the issue of redeployment from Galway. One can get consultants to come from other areas.

My final point concerns the percentage of the budget spent on mental health. Nothing irritates me more than this argument because the comparison is such a nonsense.

We have a dysfunctional physical health and budgeting system. The suggestion that we should use that as the yardstick for our mental health budget is not helpful. We have a different budgetary structure from other countries. For example, all primary care mental health services come under the primary care budget and not the mental health services budget such that the provision of counselling in primary care for an adult or child is not accounted for in the mental health budget. It is unfair to manipulate statistics to make a point without addressing the significant issues.

I appreciate suggestions. They are always welcome and I thank those who make helpful suggestions. I am always open to them.

When is it proposed to sit again?

It is proposed that we will meet tomorrow at 11.45 a.m. for a joint sitting of the Houses of the Oireachtas and, that on conclusion of the joint sitting, the Seanad will adjourn until 2.30 p.m. on Tuesday next.

The Seanad adjourned at 7.50 p.m. until 11.45 a.m. on Thursday, 21 June 2018.
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