Michael Moynihan (Cork North West, Fianna Fail)
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The purpose of today's meeting is the discussion on rights-based care for children with disabilities. On behalf of the committee, I warmly welcome representatives from the HSE: Mr. David Walsh, national director of community operations; Mr. Donan Kelly, assistant national director of child and youth mental health; Dr. Amanda Burke, child and adolescent consultant psychiatrist and national clinical lead for child and youth mental health; Mr. Bernard O'Regan, head of operations of disability services and Martina Queally, chief officer of community healthcare organisation, CHO, 6.

We also have representatives from Tusla: Ms Kate Duggan, chief executive officer; Mr. Pat Smyth, national director of finance and corporate services and Ms Clare Murphy, interim national director of services.

I remind witnesses of the long-standing parliamentary practice that you should not comment on, criticise or make charges against a person or entity in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be damaging to the good name of a person or entity. If you are directed to discontinue your remarks, it is imperative that you comply with the direction.

Members are also reminded of this long-standing parliamentary practice. Anyone joining remotely can only do so from within the confines of Leinster House. I call on Mr. David Walsh to make the opening remarks on behalf of the HSE.

Mr. David Walsh:

I am grateful for the invitation to meet the committee to discuss a range of issues concerning disability services. I am joined by my colleague Mr. Bernard O'Regan, Mr. Donan Kelly, Dr. Amanda Burke and Ms Martina Queally.

The role of the HSE is to provide a multidisciplinary team-based approach, which includes the provision of health and personal supports required by children, including children with disabilities, incorporating acute hospital, child and adolescent mental health services, CAMHS, primary care and other community services.

The national policy on access to services for children and young people with disability and developmental delay is designed to ensure that children are directed to the appropriate service, based on the complexity of their presenting need. This may include primary care for non-complex issues, children's disability network teams for more complex issues, and CAMHS for other presenting issues. For a subset of children, all three services may need to work in partnership to achieve the best outcomes for that child. The final report into CAMHS was published by the Mental Health Commission on 26 July this year and all the findings have been accepted by the HSE. Together with the Maskey report, and the findings from HSE commissioned audits on prescribing practices, adherence to CAMHS operating guidelines and service user experiences, these findings are directly contributing to the HSE's programme of work to improve services.

The Ombudsman for Children published his report, Nowhere to Turn: Children with disabilities left with no support, in September of this year. The HSE acknowledges the findings in this report and in response is undertaking a series of actions to identify, as early as possible, children whose discharge from hospital may be delayed and quickly identify and overcome issues that may impact on their discharge. These actions include a national audit of all children delayed in hospital to assess how current discharge processes are working and remedial actions. A draft assessment guidance and framework for the case management of children with complex needs in hospital beyond medical need has been developed and is currently being considered for approval.

The roadmap for service improvement for children's disability network teams has recently been published and is currently being actioned. A national review of alternative care is under way and will be completed by year end. A review of the HSE and Tusla joint protocol is also under way.

The HIQA overview report on monitoring and regulation of disability services in 2022 has been published. While the report reflects continued improvements in the quality and safety of disability residential and respite services, it also points to the need for each registered provider to increase its focus on its governance and management of services. Key learning from this report includes the need for continued attention by registered providers on governance and management, including the importance of each provider to establish the appropriate relationship between the board and executive team.

Congregated settings continue to show higher levels of non-compliance, emphasising the importance of progressing the decongregation policy and the continued work required to ensure a human rights based approach to service delivery

Legislative changes to allow for emergency accommodation will impact positively on the provision of residential services to children. The HSE will continue to engage with internal and external stakeholders, including the Departments of Health and Children, Equality, Disability, Integration and Youth, Tusla and others to promote the provision of high quality services for children with disabilities.

Ms Clare Murphy:

I thank the Chair and members of the committee for the invitation to appear here today. I am joined by Ms Kate Duggan, chief executive officer and Mr. Pat Smyth, national director for finance and corporate services.

Tusla, the Child and Family Agency, is responsible for the provision of the statutory service for child protection and welfare services across the country. In our approach to service planning and delivery, we continually seek to promote the rights of children, to ensure the full enjoyment by children with disabilities of all human rights and fundamental freedoms on an equal basis with other children.

In 2022, we received 82,855 referrals to our service, an increase of 13% on 2021, which we expect to increase up to 20% by year end. As well as an increase in the number of referrals, we have also noted an increase in the number of children and young people presenting with more complex needs, who also require access to other external specialist health and social care services, such as disability, mental health and addiction services to better meet their needs.

In responding to these children and young people we liaise with other State agencies, particularly the HSE, recognising that it is our duty as State agencies to work together to provide the integrated services that a child or young person needs rather than an individual, their family or a carer having to navigate different agencies or services, particularly at a vulnerable time in their lives.

Being in loco parentisto 5,565 children and young people in the care of the State, we know that delays and access to these specialist health and social care services, to diagnosis, particularly dual diagnosis and to intervention, continues and we see the impact that this can have on the individual's development, well-being and life outcomes.

We recognise that in many instances this is the result of an inadequate supply of suitably qualified professionals, recruitment and retention challenges, financial resources, inconsistency in service delivery models and siloed approaches to service design and delivery.

We also know that for children and young people who have experienced significant trauma in their live, particularly because of harm, abuse and significant neglect, who present with complex needs, a joint approach of clinical diagnosis-intervention from the HSE, in conjunction with child protection and welfare expertise from Tusla, is required to better understand the needs of the individual and the most appropriate intervention or response pathway.

To support this more integrated working between Tusla and the HSE, the first joint protocol for interagency collaboration between the HSE and Tusla to promote the best interests of families was agreed in 2017, underpinned by a memorandum of understanding, MOU, signed by both the Department of Health and the Department of Children and Youth Affairs. This protocol established clear expectations of joint working by both agencies at all levels to promote best outcomes for children known to either or both agencies. In 2020, this protocol was reviewed and strengthened, which has resulted in improved collaboration and integration of services for children and young people who require the intervention and support of both Tusla and the HSE. However, challenges remain within and across both agencies and further progress is required, including: improved internal service integration; clarity on the most appropriate response pathway for children and young people with dual or more presentations, such as an intellectual disability and mental health concerns, or mental health and addiction concerns; clarity on the most appropriate response pathway for children and young people presenting with suicidal ideation and self-harming but who do not meet the threshold for CAMHS; the inclusion of joint working in context of children and young people requiring access to primary care services; the need for a more sustainable, longer-term integrated model of funding for both community services and care arrangements not dependent on resources; prioritisation of children in State care - the Statein loco parentis- to all services provided by the State; and an approach to supporting young people as they transition to adult services, whose needs are such that they cannot be met by a single agency or service.

Tusla is currently outlaying €38.6 million on accommodation costs for children and young people with disabilities. The clinical management of these cases is shared with the HSE through the joint protocol with an agreement to share costs. However, due to funding difficulties in the HSE, these costs fall mainly to be met by Tusla.

In instances where a specialist assessment or therapeutic service has not been available in the public service for a child or young person in the care of the State or where there has been a significant delay in accessing a service, Tusla has commissioned same from the private sector. Our spend to date in 2023 is approximately €5.057 million on psychological and therapeutic services.

In addition, our family support services continue to co-ordinate a Tusla-led early intervention practice model called meitheal, which is designed to ensure that the strengths and needs of children and their families are effectively identified, understood and responded to in a timely way. It is an early intervention, multiagency approach tailored to the needs of the individual child or young person that identifies the various service and agency responses required in a local area to meet the needs of children, young people and families.

Over the past 18 months, the agency has also commenced the development of internal therapeutic services in all six regions to enable a general preliminary assessment of children and young people coming into State care to better inform care planning and to assess at an early stage if referral to a specialist external service, specifically disability or mental health services, is required.

As an agency, we are also concerned about a small but increasing number of families who, because of their inability to access appropriate services, such as respite, residential disability, addiction or mental health services, are volunteering their children into the care of Tusla in an effort to access such State services because they feel they have no other option available to them. We believe that the appropriate services or support should be available to these children to ensure they can remain with their families.

In 2022, we requested the Office of the Ombudsman for Children to bring together key stakeholders to discuss how interagency collaboration can be improved at a strategic level, at both departmental and agency level, to better respond to and plan for these children and young people, which resulted in a positive interagency and interdepartmental engagement. We look forward to being part of the next phase of this initiative.

I assure committee members that we are taking and will continue to take any action we can to improve services for the children and families we serve. We are deeply committed to upholding the rights of all children, but sometimes we are dependent on external agencies to uphold some of these rights. Our reform programme from 2023 to 2025 is focused on ensuring that we can continue to provide better, more integrated and timely service for the children and families we serve. We will continue to build on the integrated approach to date and on improving systems for the future.

Michael Moynihan (Cork North West, Fianna Fail)
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Before we go to members, I note that it is likely we will have the voting block during the meeting, so we will suspend. I hope the Senators keep it going while we are in the Dáil Chamber. However, it is likely that we will suspend for some period.

Without further ado, we will go to Deputy Feighan, who is in Senator Seery Kearney’s spot.

Frank Feighan (Sligo-Leitrim, Fine Gael)
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I thank the witnesses for their attendance. I wish to put on the record my thanks for their great work and service in a difficult area. Sometimes it can go without saying, but I thank them once again.

The Ombudsman for Children report entitled Nowhere to Turn states the interagency working between the HSE and Tusla remains a problem in some areas and with regard to children being left in hospitals because parents cannot provide the care they need in the home. Local disabilities managers stated, "...in some areas, the HSE does not see it as its role to provide residential care to children and that there is still conflict/no agreement between it and Tusla over which agency should fund these placements”. Can Tusla and the HSE discuss their roles and responsibilities with regard to these children and why the service gap exists? Is there an instance of child protection or disability provision? When did this issue come to attention of the agency? How many children with disabilities have been left by their parents in hospitals, respite centres or schools and how is it being monitored?

In the annual plan, Tusla notes, with regard to joint working with the HSE, issues in the executive's ability to identify appropriate funding in some CHOs have persisted. Can Tusla and the HSE discuss this further and the funding needed to eliminate this happening? Finally, is this a failure of the joint protocol for interagency collaboration between HSE and Tusla?

A lack of sharing good practice across CHOs was highlighted at last week’s public meeting that was supporting inequity in service provision. Can the witnesses discuss how they are sharing good practice across these services and the further measures needed in this regard?

It was also highlighted at that meeting that children with autism are being discriminated when they are refused access to CAMHS. These children have no assessment and end up on CAMHS waiting lists. CAMHS feels it cannot deal with autism, but it has the expertise. Can the HSE discuss this and the variance where some CAMHS are providing services for children with autism and others are not? How can services be improved to provide equal access for children with autism?

Mr. David Walsh:

There was a significant number of questions but I will try to get through them. Approximately six weeks ago, the Ombudsman for Children met with the entire senior leadership team of the HSE to discuss this report. I think even before that but certainly after that, it was clear the desire of the CEO, Mr. Gloster, is that we resolve these issues insofar as they arise internally within the HSE, such as the linkages between the acute services and community services, but also the linkages between ourselves and other agencies, and most especially Tusla. He has been clear on his direction out to our system that care planning is to start much earlier in respect of children who end up in acute settings and that arguments about money simply should not occur. We design the service, put it in place and figure it out at that point.

It is to give that clarity and avoid circumstances like we had in the past where local HSE services have not been in agreement with local Tusla services about who should pay for what. As far as I am concerned, that is a thing of the past. Where people now hit blocks in terms of funding, they need to escalate that and it needs to be dealt with at a higher level. The resourcing side and money side of that should not be an issue. What we need to do now is make sure the various professionals, both internally within the HSE and then in other agencies, are aligned and that we focus on designing the correct package of care and sourcing it. There are still issues in sourcing the correct skill sets, which Ms Murphy said in her opening statement. There are certain skill shortages. It can take time sometimes to put packages together. The way to shorten that is by having care planning happening at the earliest possible moment and preferably before a child ends up in an acute setting. I might ask Mr. O'Regan to talk about the autism pieces and other good practices we are trying to introduce.

Mr. Bernard O'Regan:

There are a couple of things. First of all, the joint protocol itself was reviewed in 2020 and that kind of reflected what had been learned from 2017. We are reviewing it again at the moment. The Deputy made the point that it was reported by the ombudsman that there is not consistency across all areas. Part of the reason for the review is to make sure we amend the protocol in order to promote the kind of work that is needed. Undoubtedly, there are circumstances where some of the children we are talking about end up in situations where they need the intervention of the State, whether that is in residential services or with significant home support packages. The nature of the need for some of those children sometimes means that the solution at that stage is not easy to find and sometimes that contributes to the delays. What we are trying to do is develop it on two fronts. One is that there is earlier intervention so that we are not allowing children and families to get into the position where they are reliant on hospital services, in particular, which are not appropriate. It is also trying to avoid a reliance on residential services until that is absolutely necessary and ensuring that we are stronger in terms of other supports including things like shared care respite and so on, which Ms Murphy also mentioned.

In terms of autism, we have been working with colleagues to develop a joint approach with child and adolescent mental health services, CAMHS, and mental health colleagues to assessment of need around autism and by extension the gateways that are there. We are working with chief officers and others jointly with primary care at the moment to develop some pathways that are better designed to support children and families to be able to access the service they need regardless of the care group. It is actually about what the need is for the child and family and that they are able to access that. That takes a bit of work. There are some examples happening in some of the community healthcare organisations, CHOs, and there is a forum in which we meet regularly with the CHOs, Mr. Walsh and the chief operations officer so that some of the learnings from those are being shared and that we build a consistent approach to it based on the learning. There are, therefore, measures happening to try to share learning but also to improve the pathways that are there. Dr. Burke or Mr. Kelly might wish to comment.

Dr. Amanda Burke:

I will comment. One of the approaches we have been looking at across our pilot sites is that autism assessments will take place within primary care and the children's disability network teams, CDNTs, and that CAMHS will have inreach there. What that means is that a child will not be passed from one service to the other, which is what the Deputy alluded to, and sit on a waiting list. CAMHS will be assessing the mental illness piece and can assess and treat while somebody is also accessing supports around the core autism supports. As I said, we rolled that out on a number of pilot sites. Initially, it has looked promising. We hope then to be able to mainstream that shortly.

Ms Kate Duggan:

I have already apologised to say that I have laryngitis so I will take this as far as I can. Certainly, we are very clear that we have-----

Ms Clare Murphy:

I think what Ms Duggan was going to say was that we are very clear that we have a child protection duty of care to children who are placed in hospital beyond medical need. Neither ourselves nor the HSE believe that any child with a disability should spend a day longer in a hospital facility where he or she does not need to be. There can be complex situations, however. For example, we had a recent situation where a young person was in a disability setting, the placement broke down and they were hospitalised and we had to try to find another placement. It is not always possible to find a placement immediately. Sometimes, we have to buy a little bit of time to put the best package together around a child or young person. What I can tell the Deputy, however, is that from a legacy perspective and a historical perspective, there were issues with regard to children being in hospital beyond the time. Since the Jack report, however, and since the renewed commitment to working together, we do not use finance now as a reason for a child remaining on in hospital. If we cannot reach agreement, Tusla will pay 100% of the bill or the HSE will pay 100%. The child will not remain in a hospital based purely on financial reasons. There can be difficulties in timing, however. We are not always able to move the young person or the child on immediately because of the lack of a suitable placement.

Michael Moynihan (Cork North West, Fianna Fail)
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I thank the witnesses very much. I call our Vice Chair, Deputy Tully.

Pauline Tully (Cavan-Monaghan, Sinn Fein)
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This is a follow-on from last week's meeting when representatives from the Mental Health Commission, HIQA and the Ombudsman for Children's Office appeared before the committee and many of these issues were raised. There was much discussion around the Nowhere to Turn report from the Ombudsman for Children's Office, which the witnesses already referenced.

They spoke about families at crisis point leaving their children in hospital longer than they need to be and even referring them to the services of Tusla voluntarily or leaving them in respite centres. Surely, the manager of the CDNT knows long before we get to that point that the family and child are at crisis point. It should never get to that point that due to a lack of services, the child ends up being basically abandoned by the family. It is the last thing the family wants to do. I am glad to hear that arguing over who funds which part is a thing of the past because it should never be about that. It is all State money anyway. What should be done is what is best for the child. One of the things that was referenced last week was that there were discussions on the need for statutory obligation for services to operate. Surely, we do not need that. Services should be co-operating for the benefit of the child without being told that is what they need to do. That is what should be happening. Unfortunately, I do not think it is because there are still children in these situations. I hear from families that children are falling between cracks due to primary care and CDNTs arguing over where they should be.

Deputy Feighan raised the issue of autistic children and CAMHS teams refusing to treat them. I refer to something Ms Murphy said about clarity and the appropriate response pathway for children and young children presenting with suicidal ideation and who are self-harming but do not meet the threshold for CAMHS. If they do not meet the threshold for CAMHS, then who does? That is ridiculous. A child who is considering suicide or who is self-harming surely does meet the threshold for CAMHS. I would like clarification on that.

The Mental Health Commission does not have remit over CAMHS. Is that something that should be changed? It has pointed out that the legislation is there to do that. That would be welcome. I feel that because of a lack of services for children and by not providing appropriate supports, we are in breach of two conventions, namely, the Convention on the Rights of the Child and the Convention on the Rights of Persons with Disabilities. They need to be addressed.

I have a question on the maximum number of children in residential. What is the maximum number? One report that HIQA presented concerned 12 young people were in a centre together. There were huge problems and there was a reliance on medication as a form of restraint. Then, when the number was halved, that did away with the need for medication and, in fact, it was much easier to manage.

We are hearing there are difficulties between the Departments of Children, Equality, Disability, Integration and Youth and Public Expenditure, National Development Plan Delivery and Reform over the funding of the disability action plan 2024 to 2026. Is that true? If an action plan for disability is published, it would be very disappointing to find it will not be funded. It gives false hope and creates considerable concern about whether it will be implemented.

Mr. David Walsh:

At the heart of all the Deputy’s questions is the fact that the services as they exist are overwhelmed. She spoke about CDNTs and that they should be able to foresee families in crisis. Many CDNTs can see that but lack the capacity to intervene because they simply do not have the resources. We have about 700 vacancies across CDNTs, with the vast majority being professional vacancies. That really impacts on their capacity to manage the caseload of children in their areas. The disability roadmap is designed to help us build that capacity but we also need the disability action plan to be finalised and resourced in order to build up the level of service so we can meet all those needs.

Alongside that, we talk about the division of labour between CAMHS, primary care and disability services. It is fair to say that at this point, none of those services is resourced to the extent it would like to be in order to be able to provide the full range of services to the number of children who present. As we try to implement the national access policy, I am wary of introducing something else that just pushes children into a service that does not exist. We need to address deficiencies in primary care as well as dealing with both CAMHS and disability services.

I ask Dr. Burke to address the question on children with suicidal ideation and thresholds.

Dr. Amanda Burke:

CAMHS absolutely has a role in the assessment and treatment of young people with moderate to severe mental illness, including suicidality and deliberate self-harm. Where it can get somewhat complicated is when a young person has an emotional dysregulation and a reaction to a traumatic situation, so that his or her mental state may vary. Under those circumstances, it may be seen as appropriate to admit someone to an approved centre or psychiatric unit. Psychiatric units for young people are regulated by the Mental Health Commission, and very appropriately so. A young person cannot and should not be detained in a psychiatric facility any longer than he or she needs to be there. This is where there can be challenges because if somebody has had previous episodes of deliberate self-harm but no longer meets the criteria, that person cannot be detained in a psychiatric facility. That is where people are asking what kind of support they can access. It is then that one is looking at community supports and wrap-around care. It involves very thorough and accurate risk assessments as to the appropriateness of a placement in a psychiatric facility at that moment in time.

Mr. David Walsh:

Returning to regulation, within the HSE we would support the entire CAMHS services being regulated by the Mental Health Commission. Regulation is a good thing and we would see it as a positive.

I will ask Mr. O’Regan to respond on the roadmap and where we want to get to with it.

Mr. Bernard O'Regan:

On the numbers of children in a residential service and the impact, our policy direction is to have no more than four people in a residential service. That is part of the decongregation plan for adult services and a framework we try to use. All our experience shows that bringing people together who have complex needs requires a lot of care and attention. There will be instances where some people cannot tolerate sharing with three or four others. We have to be adaptable and sensitive to how we support people properly. There is a risk, for example, that children or young people who are in some kind of individualised support arrangement may become isolated and disconnected. There is continuous work to be done to make sure the numbers of children who are sharing are carefully thought out. We have two rules that we encourage providers, including ourselves, to use around compatibility testing. Bringing young people, or anyone, together can look very good on paper but in reality when people have to share a space together, it may not always work out. It is about having the flexibility and adaptability to respond to that.

The Deputy asked about the disability action plan. My understanding is that the plan was approved by the Cabinet earlier this year and the Department is intent on publishing it. I have been part of meetings held over the last week that are moving it towards publication. I do not know what engagement there has been with the Departments of Children, Equality, Disability, Integration and Youth and Public Expenditure, National Development Plan Delivery and Reform. I am just not aware of that but I know the intention is to publish the plan.

Ms Clare Murphy:

We welcome the implementation of the national access policy and concur with our colleagues around the difficulties in recruitment. However, we need further conversations around services for children with suicidal ideation who CAMHS would say do not meet the service's threshold. We need to improve services in conjunction with the HSE.

Pauline Tully (Cavan-Monaghan, Sinn Fein)
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I forgot to make a point about something which was raised at last week’s meeting and has also been raised with me by parents. At times, parents who, at meetings with the CDNT, highlight issues they have and difficulties they are experiencing in the family feel there is a threat that they might be referred to Tusla. I know Tusla provides fantastic support to families but families see Tusla as a body that may take their children away from them. They also feel they are being judged as being incapable of parenting or not parenting correctly. While it is not across the board, it has happened on occasion that someone in a CDNT will tell parents that it may be necessary to refer them to Tusla for something. Parents are almost afraid to open up and share the problems they are experiencing and for which they need support. I have asked parents to stop being afraid of being referred to Tusla because it can provide them with supports, as well as supports from the CDNT. However, it should not be used in that context.

Mr. David Walsh:

That is a valid comment and we need to work further with Tusla to break down that barrier. A whole range of appropriate supports could be suitable and are available. Particularly in the context where a CDNT is struggling and a family is struggling, we need to have everything we can placed on the table in a non-threatening way. We all know there are circumstances where, on a professional basis, there may need to be a requirement to make a referral for certain reasons but there needs to be a really clear differentiation between accessing supportive services that are available across the system and making sure that families understand that they are there to support them.

Fiona O'Loughlin (Fianna Fail)
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I thank Mr. Walsh, Ms Duggan and their teams for being here and for the very well-intentioned and good work that is being carried out. I also want to express concern about where we are at.

Every child about whom we are talking and who accessed the services is vulnerable. Regardless of whether they come from the most supportive family, there will be challenges, frustrations, disappointment and sadness - all of those emotions - along the way, particularly when there is a delay in accessing specialist health and social care services, diagnosis and intervention. As we all know, that can have a very negative impact on the individual's life, development, well-being and life outcomes. It is concerning that we are falling down in early diagnosis and intervention. I accept that there are vacancies. I think Mr. Walsh said there were 700 vacancies across the CDNTs. That must be taken into account, as well as deficiencies in primary care. Mr. O'Regan spoke about better-designed pathways. Every family wants and needs a better-designed pathway so they can have a one-stop shop and they know they can go to one person with a situation and be able to find a pathway. The experience I hear about from parents at the end of their tether is that they are completely lost between all of the different agencies and waiting to get a diagnosis. One mum to whom I spoke recently has a three-year-old child. While there was an assessment, it was not a formal assessment, so the minimum wait will be 18 months. The child will then be four and a half years old but they will miss out regarding aims and even what type of education placement is the best for the child. This is a parent who has researched everything and brought her child to a private therapist. The therapist said that because she did not have this, this and this done, even though it was being paid for privately, the child could not start therapy. This is a crisis in parents' lives and for siblings.

I spoke to another parent just last week. Concern was raised last week about medication and some children being overmedicated. It was the opposite in this case, involving a ten-year-old child, with the most loving parents, who was violent, unfortunately, in school and at home. The siblings are really impacted but the parents cannot get a psychiatrist. Mothers generally do know best for their children. They absolutely cannot get a psychiatrist to look at whether this ten-year-old needs medication. Those are all the frustrations families are dealing with.

I spoke about difficult situations coming across my desk. Last week, we highlighted that there are good practices and we need to talk about them more. I know the witnesses will appreciate - it is probably the same in their situation - that when a situation comes to our door, it will always be negative. The positive stories do not come to us but there are positive outcomes. We spoke about Jack earlier and how his outcome ended up being a good, positive story. We need to look at how we share best practice across all CHOs. That came out quite strongly and it is important. Will the witnesses comment on that?

Mr. Walsh spoke about getting to the point before it becomes a crisis, and about disability managers knowing in advance of a crisis situation for a family and being able to intervene at that point. I agree with that 100%. I was in a respite centre for children aged under 18 recently and one quarter of the facility was taken up by a young person whose parents come back on a regular basis because they love their child and support them. We are in a situation in which many families are denied the little bit of respite that will make all the difference. Perhaps, if that family had gotten help before, the situation I am describing could have been avoided. It is about trying to figure all of that out and a pre-emptive strike before it gets to that crisis. Will the witnesses comment on that? We are talking about scenarios of children being left in respite care.

The HIQA overview report on the inspection and regulation of children's services referenced the lack of suitable alternative provision, which meant that a few children remained in placements that were no longer appropriate in meeting their needs. Will Tusla discuss that as regards ensuring those children are in a more appropriate placement and there is a place for others? I thank the Chair. I know I went over time.

Mr. David Walsh:

I thank the Senator. What she described is where we have failed families, not just the child. Families do not abandon children; it is simply that they are not getting the supports they need, in the vast majority of cases. That is at the heart of this matter. On how we are trying to change things, the disability roadmap and action plan are critical in building capacity. Many of those things, like blocked respite, relate simply to a lack of capacity. Mr. O'Regan spoke earlier about suitability of placements and the need to be flexible and to move people around to get the best fit. That is difficult when you simply do not have capacity. We must grow more capacity. I will ask Ms Queally to talk about the work she has been doing to get the one door piece working. That would be really useful. As a chief officer, she has responsibility for the full range of services in her area, including primary care, CAMHS and disability.

Ms Martina Queally:

As Mr. Walsh said, it is really important that all of the services work together in primary care through to disability. As Dr. Burke said, the in-reach from CAMHS teams is important. We always try to give families additional support if we feel they need it but, unfortunately, sometimes that is not enough. The unfortunate circumstances the Senator described occur occasionally when it is simply not enough. We have been in a situation in which respite has been used, even by us, sometimes, when we know a family is at the point at which they cannot cope. We are acutely aware of the impact that has but sometimes these services must be developed, as Mr. O'Regan said. They are not just off the shelf. The child's needs must be met in a particular way and we frequently have to procure a residential place, if required. Concerning ongoing work, we are working with our disability services, CAMHS and primary care teams to look at an integrated model. We have centralised referrals in the CDNTs so they have full view of the demand presenting to the CDNTs. Demand is up across the board. In September, we had the same number of referrals in CDNTs as we had for the full year last year. Demand on the disability side is up. We are 50% ahead of where we were last year on CAMHS. Demand in both services has substantially increased. Equally, as Mr. Walsh said, it is important that we strengthen the primary care end for early intervention with psychology, speech and language therapy and physiotherapy at the earliest possible point in the child's life.

All of our children see our public health nursing service and our area medical officers during their developmental screening as a baby and in the first year of their lives. Our ambition also is to strengthen that front end of our service and to make a much more seamless progression on, where the child needs disability services. One will see in Sláintecare and other documents where that stepped model of care is referred to. That is our ambition, that we would work with that much more integrated approach to services.

We have a waiting list for children who require residential services and more respite and support, and we are working towards having greater capacity right across the board. We are not at full capacity on our CDNTs, primary care teams or CAMHS teams, so that is work that is ongoing with regard to making sure those teams have the full range of staff available.

Mr. Pat Smyth:

From Tusla's perspective, obviously where there is a child protection issue, we have children who are in accommodation with disabilities. At the moment, we have got approximately 70 kids in those placements and in the majority of those cases, Tusla will agree to take on the care of those kids through the joint protocol. Tusla are the main owners of the placements in those conditions.

The protocol has been useful over the past while to ensure there is better clarity on that. Mr. Walsh indicated earlier that we have reached a point where the arguments over who pays for those are a lot less than they are but there is still an area where there is a lot of resources required. Those cases, together with around 30 of what we call our legacy cases, which are there for a long time and which Tusla look after, cost almost €40 million. It is an expensive business, and one that requires a lot of resource. Both agencies have been working to try and ensure that is not an issue over the past while.

Mr. David Walsh:

I have one last comment that relates specifically to CAMHS. We came to the conclusion some time ago that CAMHS needed a dedicated space for itself within the structure so that it gets the attention towards development that it needs. That is why my two colleagues beside me are here, Dr. Burke as national clinical lead and Mr. Kelly as assistant national director specifically for CAMHS. Their task, along with that of myself and others, is to drive out a development plan for CAMHS and to acquire the necessary investment to develop those services and bring them up to the level where they need to be, with a consistent approach across the country to a higher standard.

Dessie Ellis (Dublin North West, Sinn Fein)
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I thank everyone for their contributions. We had the Ombudsman for Children's Office before us last week, and we have the HSE and Tusla in this week. The issue that I kept on thinking about was the role of public representatives when it comes to, as I have experienced, making complaints regarding abuse and different things going on in a house. I recall making a complaint to the HSE over a particular incident. I am curious as to what the process for public representatives is. If someone complains to me that they think there is abuse or something going on in a house that is detrimental to a child, that the child is getting beaten, that there are mental health issues and all of this going on, what should we do as public representatives? I am curious to hear the witnesses' thoughts on that.

We talk about the voice of the child, about the child being at the front, and the rights of the child. What happens in cases where children are in residential care, they keep running away and they have no parents as such? They just have, say, relatives or people they keeps running to, and there is a problem with that. What are their rights in addressing that? With Tusla, is there legal advice? Are they entitled to legal representation? I would like to know how that is addressed. It appears, in a case that I am aware of, that the child has no rights. The child is totally distressed and does not know what to do, and is getting more distressed because of being refused contact with someone. There are reasons, and I am not going to go into that. However, I am just curious about the approach on that.

I also want to ask the HSE to discuss whether a national set of standards should be implemented for individuals with autism and who have dual diagnosis. I think this has been mentioned previously. I want to know where we are with that. Is it being addressed? Are we anywhere near doing that?

Regarding complaints, I was thinking about the CDNTs. I know there are problems in filling out those teams. Is Tusla anywhere near that? I know there are different areas, and we have so many of them. Are the teams being filled, and how many of them are there across the country? There was a figure mentioned before but that is obviously a big drawback in addressing a lot of the issues. Maybe someone could explain that to us.

Michael Moynihan (Cork North West, Fianna Fail)
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Maybe we will start with Tusla.

Ms Clare Murphy:

I might take the first two questions. On what to do if a public representative has a concern about a child, we have in place in this country the Children First guidelines for the protection and welfare of children, and what they say is that anybody - any member of society in Ireland - who has a concern about children should report the matter to Tusla. The same would be incumbent on the Deputy, in that if he had a concern about a child, that he should contact Tusla either through our website or by calling us. That is our responsibility. Anybody who has any concern about a child can make direct contact and give us the details, and we will then follow up.

Regarding the voice of the child, often if children in care are in care from a legal perspective, they have what is called a guardian ad litem. That is somebody who the judge appoints who is the voice of the child, and who is there to promote the best interests of the child. If they are in care maybe on a voluntary arrangement as opposed to through the courts, it would be whoever the allocated worker from Tusla is. It could be a childcare worker or it could be a social worker, and that is the voice of the child. That person should be promoting the rights and best interests of the child. If one comes across a situation where that it is not happening, we would be very happy to hear about that. It would either be the guardian ad litemor the social worker. We also have a complaints system for young people in our care, making a child-friendly process where they can make a complaint if they wish to do so. Their rights would be vindicated by either the social worker, childcare worker or the guardian ad litemappointed by the court.

Mr. David Walsh:

It is interesting. I was thinking of the north side of Dublin, and I cannot remember the exact number of CDNTs but there is a very clear divide. The CDNTs in the north of the county, where in my mind I would have thought it would be easier to recruit into, have the biggest problem with recruitment and retention. The ones on the city side are pretty much up there with regard to their complement. We get that right across the country. There are pockets where they are pretty much up to their complement, and other pockets where they are way down. Even those teams that are up to their complement, those are complements that were set at a point in time and they have not grown in line with the growth in demand. One of the functions of the disability action plan is that services would grow to meet demand.

It is a mixed bag around the country, however, as to where teams are with their resourcing. There are 91 CDNTs throughout the country, and many of them are led by some of our funded organisations rather than the HSE. Within those two, some of the retention issues are driven by the pay issues that played out recently in the dispute. It is to be hoped they will be addressed if that settlement is accepted by the members, but we need to continue to grow those teams and to address specifically the areas that have difficulty recruiting.

I will ask Mr. O'Regan to talk to the question about national standards.

Mr. Bernard O'Regan:

My understanding is there is not a specific piece of work to develop a specific set of standards for the autistic community. Currently, I think there are something in the region of 11 sets of standards that HIQA has published, and they are subject to ongoing review. In my view, the importance of developing all those standards is that they should consider the whole population, that is, in their design they should reflect the needs of the autistic community, people with Down's syndrome, people with mental health needs or whatever else it might be rather than a specific set of standards for each type of disability or each particular care group. My understanding is that is the kind of approach HIQA would take in the development of standards.

Michael Moynihan (Cork North West, Fianna Fail)
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We have a vote in the Dáil Chamber. I have asked Senator O'Loughlin to chair the meeting in my absence. I think she is due back here immediately but, in order that Deputies can go to the Dáil Chamber, Senator McGreehan might take the Chair until Senator O'Loughlin comes back. We have three Senators present, two of whom have contributions to make. I am not sure whether we are heading to the voting block, but we will back as soon as we can.

Tom Clonan (Independent)
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I thank everybody for coming in. It is one of the habits of these Houses to sit late.

We had a very interesting and engaging set of witnesses last week, particularly Dr. Hillery, the chair of the Mental Health Commission, and Professor Lucey, who is the Inspector of Mental Health Services. They said that, in their opinion, CAMHS was in failure and was failing children and adolescents in Ireland. They both emphasised that was not a criticism of the people who work in CAMHS, but it probably flows from the point made repeatedly about the difficulties in recruiting and retaining staff. Last year we heard evidence from Paul Reid, then CEO of the HSE, that, similarly, the progressing disability services programme and CDNTs were in failure, and I know the roadmap intends to address that. In Mr. O'Regan's evidence he said repeatedly that it is about capacity and trying to recruit the staff. There are 700 people not recruited to those teams, and that seems to be echoed across the board. We are short 700 primary school teachers, I think. We have problems within An Garda Síochána and elsewhere, in other parts of the public service. My view on that is that it is probably an echo of austerity measures that were implemented during the financial emergency. To repeat what Dr. Hillery and Professor Lucey said, it is not a criticism of anybody here or anybody who works on these teams. They are starting from a position of intellectual honesty in that they say they have a serious problem. I really appreciate Mr. Walsh's comments because they align with my family's lived experience. Because of these constraints, through no individual's fault or negligence, the needs of the majority of families are not being met.

I have a couple of specific questions about that. I will address the first to Mr. Kelly. I congratulate him on his appointment and thank him for coming to Ireland. What we need is for people to come to work in our system. I note that he worked in the Pennines with the NHS and in Australia. I do not know what brought him back but we are delighted to have him. In his experience internationally, are we completely out of step with the situation as it applies in, let us say, Australia or the UK? I am sure they have their challenges there, but are we in a significantly more challenging position?

These two questions are interlinked, so I invite anybody to answer them. Given that we are at this moment of crisis, is there anything we, as the Legislature, can do to assist? Professor Jim Lucey said last week that he would like to have more regulatory powers and to have those powers expanded. Specifically, is this an opportunity to redesign CAMHS completely? Do the witnesses think the model of CAMHS we are operating at the moment is effective or efficient, or could it be better? Is this an opportunity to redesign how CAMHS works?

There was also a brief discussion last week about the appointment to consultant posts of doctors who do not have higher specialist training. In that regard, Dr. Hillery was very specific. He said there are adolescent and child psychiatrists who have really impressive qualifications, who have gone abroad and who have really upskilled themselves in areas such as autism and areas of special interest. He said we have to try to find a way to attract them to work in our system because they tend to gravitate elsewhere. He asked how we might facilitate that. The witnesses on that day also said this was not a phenomenon that was as common in other specialties or other disciplines. Does the HSE have a view as to why it would appoint people who do not have higher specialist training into these critical posts? In the Kerry CAMHS scandal, for want of a better word, my understanding is that some of the inappropriate prescribing was down to somebody who was not adequately supervised and who did not have that higher specialist training.

We also heard evidence on the day Paul Reid addressed the challenges for the progressing disability services programme and CDNTs. We had a very senior witness who said it was his view that psychiatrists should not be the leaders of the multidisciplinary teams. I thought that was an extraordinary assertion to make. In the CAMHS teams, do the witnesses have a view as to who should lead the multidisciplinary teams in that area? My view is that it should be the psychiatrists. It is my understanding that in other areas of medicine it would be considered unusual if some other member of the team were to step up and say, "I will manage this."

Mr. Kelly might have a view on my last question. What is it about our system that we have hundreds and hundreds of wonderful occupational therapists, OTs, physios, speech and language therapists, psychiatrists and oncologists heading to Canada, Australia and New Zealand? Last Christmas, I think a photograph was taken on Bondi Beach of something like 230 medics. If only we could repatriate them.

It is probably an echo of the austerity measures. In redesigning the roadmap or the way forward for the CDNTs, the witnesses are working very hard to add value and impact following the CAMHS crisis but is there something we could do to try to attract people back? I know the purse strings are held by the Departments of Health and Children, Equality, Disability, Integration and Youth and, therefore, it is not straightforward. Mr. Bernard Gloster has been very vocal since his appointment about the need for funding.

Fiona O'Loughlin (Fianna Fail)
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I will ask Mr. Kelly to respond the question directed to him first.

Mr. David Walsh:

I would like to say something first. Mr. Kelly and Dr. Burke are here because we want to do things differently in CAMHS. They can both go into some detail about their plans, which centre around having a focus on CAMHS, making sure the correct governance structures are in place and making jobs attractive to people. It is about bringing a different lens to it but I will let them speak for themselves. That is the reason they are here really.

Mr. Donan Kelly:

It is important to acknowledge the good clinicians that are working in CAMHS at the moment, particularly as they are working in quite strenuous circumstances given the demand that is out there, as the commission's report highlights. There is lots of good work going on, although there are issues with demand and with siloed working.

On the first question regarding how we fare in comparison to other jurisdictions in the provision of services, demand is an issue in both the NHS and in Australia vis-à-vistheir services. We have an opportunity here in the context of our CAMHS improvement programme and the child and youth service programme. Sharing the Vision is quite a clear document in terms of the development of mental health services and a lot of the 31 recommendations in the Mental Health Commission's report read across to things that we will be doing through that programme of work.

In terms of where we are on the governance issues and some of the things the commission has highlighted, our office will have a renewed focus on the standardisation of the operational guidelines in CAMHS. We have done a baseline audit and it is looking like an improving picture. The other piece is the demand that is coming through and the actual resource that is there to deliver the service. On top of that, it is about integrating the various levels of pathways, particularly around early intervention. Many of the models elsewhere that we would be hoping to implement in this country bring together all of the providers from the primary care level, education, our colleagues in Tusla, our colleagues in organisations like Jigsaw, Pieta House and other voluntary, community and social enterprises, VCSEs, to provide a much more robust pathway whereby people get access from a very early stage.

My involvement in both Australia and the UK has been in setting up those single points of access for services so that there is a one-stop shop. That is something we are looking to replicate in the work we are doing with disability services at the moment and that we will bring in down the line, hopefully. That is a brief outline of the situation. We are starting at a low baseline. There are things we need to do internally in terms of improvements to the governance structures and that work is underway at the moment. It is also about keeping a strategic focus on the longer term, about building up a more needs-centred and person-centred approach to care rather than a stratified system which tries to box people into one team or another. Young people and their families invariably fall between services because of that siloed way of working. We need to have a more joined-up service.

That in itself will bring efficiencies, which was the subject of the Senator's second question. At the moment, a lot of referrals that come through from primary care will go not only to CAMHS teams, but to CDNTs and primary care psychology services simply because people know there are long waiting lists. Again, more integration will help with some of that efficiency.

I will skip to the last question and let my colleague, Dr. Burke, answer the question on non-consultant hospital doctors. The Senator is correct that there is a big flow but it is not a problem that is particular to the healthcare system in this country. It is the same in the UK, with people going out to Australia to work. We see them on Bondi beach but the HSE is working on its recruitment and retention policies. If we can make services better for people to work in, which is part of the issue at the moment, we will naturally start to attract people back.

Dr. Amanda Burke:

The Senator asked if is there anything this committee can do to help. CAMHS has been chronically underfunded and we have a lot of catching up to do. We need a commitment to multi-annual funding so that we do not have to go back every year and pitch our strategy. Our workforce plans depend on a number of years. We have to resource the universities to produce enough graduates and then we have to get those graduates into training programmes. We need to be able to plan and to know we have the resources available to do that going forward.

The Senator also asked if this is an opportunity to redesign the system and the answer is yes, absolutely. Sharing the Vision is a document of its time. It was great in that it laid out how we plan services but multidisciplinary teams working in isolation cannot provide everything. We have to provide evidence-based care and the evidence base is for practitioners who have fidelity to the models, particularly in psychological therapies, that they are doing them a lot and that there are proper supervision structures. However, we cannot do that in every multidisciplinary team. As well as resourcing our teams, we also need to work on a clinical directorate model that shares resources across teams for those more specialist types of therapies. This also provides collegiality, peer supervision and lends itself to clinical audit. The Senator referenced Kerry and it was an example of an isolated team without enough staff to provide adequate supervision to practitioners. A clinical directorate model across a regional health area, RHA, is a much safer practice, analogous to what happens in hospitals.

We have moved forward on this. This year we have five pilot sites for the CAMHS hubs and those hubs are providing a real alternative to inpatient care for young people. They are also being staffed with very experienced practitioners who can be shared across a region and who can provide a level of support. Those kinds of things matter in the context of attracting graduates back. Terms and conditions are not just about financial rewards. On foot of the new consultant contract we have certainly seen a difference in terms of more candidates applying for posts. That is starting to work, which is really positive but it is not just abut that; it is also about collegiality, having good colleagues to work with and being able to have one's own area of expertise as well. In CAMHS we have not done that. We have not allowed practitioners who have a special interest in an area to set up a clinic in a region that can be a tertiary referral centre. We are resourcing CAMHS, particularly through the CAMHS hubs, with quite sophisticated telepsychiatry, which means we can spread the service across the country. There are lots of practical things we can do to improve terms and conditions for people and to attract them back but we need this committee's help.

Tom Clonan (Independent)
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I was really struck by something Dr. Hillery said last week. This is going to sound like a statement of the obvious - I will not use the full Monty Python analogy - but obviously children get sick and the most common pattern of illness is in the area of mental health.

It is a vital service. I know that Dr. Burke is in a lead role in this area. I wish her the best of luck in her new post and in working together. She needs whatever support is there. There is a growing public awareness of how critical it is. Deputy Ellis talked about people in crisis and I am sure Senators McGreehan and Flynn will make similar contributions.

Mr. Pat Smyth:

The Senator asked what can he do, which is sometimes a dangerous question to ask. From Tusla's perspective, we are always conscious of the fact that we are in loco parentisfor 5,500 kids whose constitutional rights have been failed. The State has, therefore, taken over their care from their families. One of our biggest needs is to ensure that those kids, because they are being looked after solely by the State, have access to assistance through the rest of the State, where they can be prioritised. That does not only relate to mental health services, which are extremely important and there are obvious constraints in that regard, as they also need support through all kinds of other primary care services and supports other than health services. We need to think about ways to provide that support. We try to do that with the HSE and at other ports of call. It is almost something that should be there as a first ask because those kids are a priority for the State.

Erin McGreehan (Fianna Fail)
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Our guests are all very welcome to our meeting. I look at our eight guests and think they have an enormous responsibility in respect of thousands of children and their futures. The success or otherwise of their jobs depends on them. They are in an incredible position. Many people are falling between stools. As Senator O'Loughlin said, we only ever hear of the bad and hard stories. Many of us have personal experience or know people who have had wonderful experiences, who have got proper help and thrived and succeeded after proper intervention. When we then hear the bad stories and hear about the waiting lists, it is even more frustrating because we know we have good people who know what they are doing but we cannot get children access to them. That is frustrating.

Mr. Smyth of Tusla mentioned that 5,500 children are in the care of the State. How many of them are in specialist care? How many, because of the lack of access to care and other interventions, including medical care, therapy and specialist interventions, have ended up in the State's care? I met representatives of Tusla in my area recently to discuss how things were going for them and the challenges they are facing and they mentioned that this is a significant challenge for them. They told me they are stuck and things get so bad for families that there is nowhere else to turn other than to Tusla, which has a statutory obligation to find accommodation, regardless of whether it is suitable. Even if it is imperfect, that accommodation has to be provided. It costs an enormous amount of money because of the domino effect on what comes thereafter. When do our guests, as stakeholders, get together and sit down to discuss these challenges? How often do they meet to discuss challenges within Tusla and access to care? I note Tusla has spent €5 million to access private care. It is a State body but is accessing private care. That does not make sense to me. I am thinking of the staff who could have been employed and the efficiencies that could have been built into Tusla's systems if that budget were to be used somewhere else. How often do our guests meet to discuss challenges?

Let us consider a situation where a case worker in Tusla has a family of concern. That social worker sits with the family, including the children and the mother, concludes the family is in crisis and asks why. If the crisis is that there is a child with mental health difficulties, who is screaming out for services or therapies, is there space for that child to be prioritised to stop Tusla having to take that child into care? Do those conversations happen? In that position, do our guests identify that a certain child is very vulnerable and understand that if there is no immediate intervention, it is more than likely, based on their experience, he or she will have to be taken into State care? How do those mechanisms work at a local and regional level?

We know that foster families are important. They are a linchpin. If we did not have foster families, Tusla would be in serious trouble. What extra supports are available for foster families if they need support, for example for a child with disabilities? They may need help to adapt a home to provide for a sensory room, or extra help in the family home to be able to support that child. If we provided that support, the child would not need the HSE as much. What wraparound supports are available? I know a family with a need for a sensory room at home. The little girl in question is wonderful but needs a sensory room to be able to thrive. She is receiving some therapies but the provision of such supports would be better and would balance things out. What wraparound supports can Tusla and the HSE provide? Can they, for example, provide the likes of sensory rooms?

Ms Clare Murphy:

The Senator has asked a number of questions. She asked about interagency co-operation. From the first time we get a referral, we liaise with the HSE. At the ground level, the social worker liaises with the public health nurse, the speech and language and occupational therapists. From that level up, there are different layers. Where a social worker is liaising with the public health nurse, there is what is called a professionals meeting held, which includes the attendance of representatives of the HSE. There is sometimes a child protection conference, which has representatives of the HSE. At every juncture of a child's life, we are continually liaising with the HSE and other external providers.

Under the joint protocol, we have different levels of engagement which go from the granular level of the principal social worker, PSW, and the area manager to the CEO. There are different levels of engagement. We have built-in systems whereby we are communicating with each other all the time. That is the first thing to say.

The Senator asked about the breakdown of the different types of care we provide. We have 482 children in foster care. There are 259 children in residential care. I think 12 children are currently in special care. When the Senator asks about special care, does she mean that in terms of High Court-directed special care or special emergencies?

Erin McGreehan (Fianna Fail)
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I was talking about either situation or both situations.

Ms Clare Murphy:

In special emergency arrangements , we have 167 children today. In special care, which is court-directed care that takes away the liberty of the child for its own sake, we have 12 children.

The Senator also asked about supports for foster carers. We have a new national foster care strategy, which talks about the various supports we are going to put in place, including mentoring, peer support and a national lead. The Senator mentioned sensory rooms in particular. We are always open to any proposal made by the social work department to us in management about something that would make life easier for the child. We do not always have the money to provide a sensory room but we do have systems whereby we can provide adaptations to houses.

Obviously, we liaise with the Department of Housing, Local Government and Heritage and our colleagues in the HSE. We really try to do everything we can because we know that the best place for a child to be once he or she cannot live at home is foster care, as opposed to residential care. We do our best but we are sometimes constrained by finance.

Mr. David Walsh:

The Senator mentioned a figure of more than €5 million that Tusla spends on services for children you might reasonably expect the HSE to provide. There are probably many more millions Tusla spends on other things that, if you were starting from scratch, you might say was HSE-type of expenditure but I am glad Tusla does provide the service. I am sorry the HSE does not have the capacity to provide those inputs directly. The HSE does end up purchasing quite an amount of service from the private system to support children in our orbit. I might ask Mr. O'Regan to comment on the other issues relating to the interaction from the ground up, which was outlined pretty clearly by Ms Murphy, and how we approach those things.

Mr. Bernard O'Regan:

I think the same as set out by Ms Murphy. It is really important that communication is at the closest point to the child and family. In many respects, when it is escalated through a system either to a chief officer or to Mr. Walsh or me, in a way, it is because people have reached intractable issues with which they need help. Our role primarily is to find some solution. There are very strong efforts to make sure that those working relationships at local level do continue and are at the forefront and the starting point.

The funding issues that were mentioned are challenging for both organisations. This year to date, the HSE has spent €37 million in supporting children in residential services - partly fully funding services and partly co-funding with Tusla. Between the two agencies, the State is committing very substantial moneys. Both agencies are challenged by a situation where they are very reliant on the private sector. We certainly share some ambition to see how we can maximise value for the State in the relationship, be it with the private sector or other sectors.

In terms of support for foster carers and flexibility around the use of moneys, we are very conscious of developing other services like home sharing services as part of the array of services on offer. I think I referred to this earlier. We do not want a situation to arise where it is all or nothing. There are lots of things in between. Tusla has a very good model underpinned by legislation around foster care. We are looking to enhance our home share services and build those kinds of models and shared care in order that there it is not a case of from home to residential but there are things in between that might serve children and families really well.

Eileen Flynn (Independent)
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I attended last week's meeting. There is no solution when it comes to good-quality mental health services for young people with disabilities. To the best of my knowledge, CAMHS continues to fail young people with disabilities, particularly autistic children. Last week, we heard from the head of the Mental Health Commission who said that CAMHS was discriminating against autistic children. I have not heard CAMHS acknowledge today that autistic children or children with other disabilities not having access to it is discrimination. I have a list of emails as long as my arm from people looking for access to CAMHS for an autistic child. In the next 15 to 20 years, we will see that a service that was meant to look after all young people excluded some children with disabilities. It is wrong that this is happening in 2023. I am not an expert. I am not a professional mental health worker. Why does CAMHS not support autistic children? What is the solution?

Senator O'Loughlin spoke earlier about Jack's case. Let us try our best and focus on the positive but, unfortunately, as a member of the Traveller community, I see young children with disabilities who do not have equal access to services. I do not see much good practice on the ground. It is a horrible thing to say because as my colleague said, the people around this table are very professional and want to see positive changes for all children, including children with disabilities. While I love this committee, I do not like bringing in ordinary people who have little or no supports and where services are overcrowded. I go back to my nephew. He was 17 and was failed by mental health services. I am talking about mental health institutions for young people. I do not see any fit-for-purpose mental health services for young people in this country. I know we have St. Patrick's Hospital but it is overcrowded. I am very privileged in that so far, none of my children have been diagnosed with any disability but I have seen it with my nephew and young Traveller men with disabilities. I am just so passionate about it because I see it and I want to come in here and congratulate people on all the work that is being done but when you see young men like Paddy, who is now in his early 20s, being failed, I would not even say publicly what he is going through because those mental health supports were not there for him when he was 17. What is the solution?

There were three recommendations that were not implemented. Could the witnesses from the HSE talk about them and how we can implement them? I apologise if anyone thinks I am just giving out but it is very difficult to see good practice on the ground when you see young people with disabilities being failed. Again, it is the fault of nobody here but who is to held accountable when these children are failed?

I have said numerous times at this committee that we will look back in the next 20 years and see how much we have failed young people with disabilities in this country. Just as the State had to apologise for mother and baby homes, it will have to apologise to young children with disabilities in this country because we are genuinely failing them. The committee is trying its best, on a cross-party basis, to bring about better change by bringing in witnesses like those present to ask what the solution is and what we can do going forward.

Eileen Flynn (Independent)
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Sorry, my husband is ringing me about the kids going to bed.

Michael Moynihan (Cork North West, Fianna Fail)
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Real-life challenges, exactly. We will start with the HSE.

Mr. David Walsh:

Does the Chair want me to proceed?

Michael Moynihan (Cork North West, Fianna Fail)
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Yes, please.

Mr. David Walsh:

We will all have to talk about the range of matters the Senator raised. Even within that, there is a huge number of issues. The Cathaoirleach mentioned real life, but what we are putting forward is that real life does not fit into a CAMHS box, a disability box, a primary care box or a Tusla box. It can be a mix of all of them. The take-away I took from the Mental Health Commission report, and the most damning bit within it, was the lack of integration. Dr. Finnerty, who penned the report, was very clear that this is the big failure. Our platform today, both internally in the HSE and with Tusla, is that while we need to build services, those services need to be integrated so that kids do not need to fit into a particular box to get a service. As Dr. Burke said in response to one of the earlier pieces, if someone's primary condition or range of conditions means that he or she is probably best hosted within a disability service, then CAMHS needs to be reaching in to deal with the CAMHS-related things in that regard. Likewise, we need to support kids in care in a better way. There is no one single or boxed solution. We just need to grow and work together, and have interlocking policies and practices that will protect children.

There were also contributions about the Jack recommendations.

Mr. Bernard O'Regan:

The outstanding recommendations are being worked on. One is at the point of completion, while we indicated we will work towards having another completed by the end of the year. We are on target to be able to do that. We are working on the third recommendation for the next quarter. We are progressing them. In and of themselves, they are recommendations about ways of working. They were not recommendations whereby when we do this, that will be the magic wand that is the answer. It is more around setting out, in the language we used earlier, pathways or directions, either for the HSE or for what we are working on collaboratively with Tusla, so that we are confident all the time that what we are doing is the best we can do and are constantly reviewing it to be the best we can be at each point along the way.

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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A lot of my questions have been answered, unless Senator Flynn wants to come back in.

Eileen Flynn (Independent)
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I will look back over the answers later.

Mr. David Walsh:

We are happy to meet the Senator directly as well.

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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I agree with Senator Flynn. As she said, I always feel that if a family is affected, it is only then they see how they react and how the system is failing. I see many challenges within the system. There is no joined-up thinking. Senator McGreehan spoke about sensory rooms. I will give examples of this. I cannot get my head around these things. We are dealing with the best people in the country but sometimes I wonder where common sense prevails.

I worked with two or three cases of children with disabilities in the area where I live. We wanted a sensory room. In fairness to Carlow County Council, the only way people can get a sensory room is through the local authority, but most local authorities do not have an occupational therapist to assess a child. First, and it makes my blood boil, people go to their local authority - I am not complaining about Carlow, which has its occupational therapist and, as the Cathaoirleach will say, I will say "Carlow" a hundred times - which cannot assess the child. The family then has to pay privately to get the child assessed. The first thing all the Departments and agencies should be doing together is talking to the local authority and setting up some sort of common sense approach whereby a child with a disability who needs a sensory room can be assessed. A child cannot be assessed unless a family pays. I know of families who had to borrow money to pay privately. That is unacceptable. In fairness to the councils, they have done some assessments but many more rooms need to be done. I ask now that the first port of call be local authorities for children who are lucky to be assessed.

My voice is gone too. Like Ms Duggan I am doing too much talking. There are 1,496 kids on the long-term waiting list for therapies in Carlow and the south east. The demand for these occupational and speech and language therapists is frightening. We have two CDNTs in Carlow that I am sure the witnesses are aware of, namely, Shamrock Plaza and Bethany House. There is no-one in Bethany House, or just one person. We now have a CDNT facility that has no staff and everyone wants to go to Shamrock Plaza because it has more staff, but there is such a shortage. There are children looking to go into primary school who are not being assessed. All the representatives have spoken about the money but the first thing they will say is "early intervention".

I feel that we are neglected in Carlow. There is an issue with CHO 5 when it comes to staffing. I am not blaming staff by the way. I am not here to criticise anyone but the problem is that people have lost faith in the system. Families come to me and some of them are so upset. One particular child is in a very bad way. She has not had speech and language therapy for years. Another child is waiting for a chair. Another is waiting to get into a school but because she has not been assessed the school does not now know whether it can take her. There are huge issues and we have to face them. I am not saying this lightly. I am angry and tormented for families who come to me who are not getting the services. It can be imagined how bad I would be if I had my voice. I will ask all the witnesses this. As I said, I know it is challenging and that they are doing their best, but they need to sort out those children who are not being assessed. They need to get staff. We need to do something because we are at a crisis point.

I will go to Tusla and Ms Duggan. Yesterday, I was a little taken aback when I saw that Children at Risk in Ireland, CARI, is the only national agency supporting child victims of sexual abuse and their families. It is estimated it costs €1.1 million to run the service each year but Tusla has confirmed the budget for 2024 is capped by nearly €340,000. That is a funding drop of 55%. I know Tusla has looked at this. I do not even question that, but is there a reason for this drop?

These services are so important.

I will give another example, but I am nearly finished. Many of the officials know Carlow very well. Mr. O'Regan and Ms Duggan do. We got Holy Angels Day Care Centre into the capital plan. It is a facility for children with disabilities. It operates out of prefabs. For 40 years we have had children with profound disabilities in prefabs. I have been on the board for the last five years. I think there is a bit of a hold-up in the capital plan. The CDNT is meant to go with Holy Angels, but the centre cannot stay in the prefabs any longer. When we come to emergency cases like this, what is the plan to have children in a proper facility in 2023, going into 2024?

I could stay here talking to the officials all day. I could give them 100 cases. The officials are the people who can change lives; they can change families' lives and change children's lives. I ask them to work together so we can make those changes. They can only be small. The Minister of State, Deputy Rabbitte, was looking at those who go private to get occupational therapy services. The Cathaoirleach would be aware of that as a means of getting children assessed. I think the Minister of State did a pilot scheme on it. We need to get that to Carlow and we need to get other interventions. The officials have had a lot of questions. I had a lot more, by the way; I must have another 20. The officials may have answered enough of them, so they may come back to me. I will come back to them on all these questions. I will keep ringing them for meetings and I will keep giving them the cases. I thank the Cathaoirleach.

Michael Moynihan (Cork North West, Fianna Fail)
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I thank the Deputy. We will start with Tusla and then go to the HSE.

Mr. Pat Smyth:

I will give an answer on CARI on behalf of Ms Duggan. It is important to say we are in discussions with CARI all the time. The services it currently delivers are only partly funded, and have only ever been partly funded, by Tusla. We have worked with CARI over the last number of years to increase those services, but a lot of its services were previously funded through philanthropic donations rather than by the State. As to what the CEO asked in terms of the demand from the agency, it is a figure of about €1.2 million. This year we have been funding CARI to the extent of about €750,000 and are going to give it additional funding to take it to the end of 2023, but the CEO has sought to look at the model of care CARI is delivering to see how it can be delivered within the funding that is going to be available for next year. Within those discussions we can see what funding is there.

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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Okay.

Mr. Pat Smyth:

There is a process there and quite a bit of funding in there already, but we accept that a lot of that funding is once-off. However, it has not been State funding to date so what CARI is looking for is an increase in the State funding to deliver those services.

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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Okay. I thank Mr. Smyth for clarifying that.

Mr. Pat Smyth:

There is no reduction in help.

Mr. David Walsh:

The Deputy mentioned Carlow County Council and the OT and it goes for any other city or county council as well that we need to have an understanding. If it is a way of unlocking funding for people we absolutely have to come up with something. I do not care if it is 26 different ways of doing it as long as it works.

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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Yes, absolutely.

Mr. David Walsh:

We are happy to take that away and see if how can make it work and not just think about it. All those things are really complementary to what we want to do, which is support those families. I am conscious that in CHO 5 - the Deputy mentioned the two CDNTs - that the one that practically ceased to function is a huge concern locally to the chief officer and head of disability services. It is probably one of the services most impacted nationwide by our inability to retain people for all the reasons we have talked about, such as that they are not attractive places to work because we do not support them. It is a question of how to convince people we now have a framework that encompasses CAMHS, disability and primary care and if a person takes a job with us it will be doable. Many of the existing teams, no more than the parents of the children, are completely burnt out-----

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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Yes, of course.

Mr. David Walsh:

-----and we just need to support them to get them back up on their feet and we need to convince them we are going to follow this through. That is our combined task on this side of the table. Obviously, we need to convince the Deputy and other representatives as well in relation to that. We are trying to build through the road map and through the action plan to show a commitment to people that we are trying to build things up. We have a lot of convincing to do. From speaking to people who have worked on these CDNTs, they are very frustrated. They are very professional people who really are incredibly disappointed they cannot provide the type of services they want to to all the families. The Deputy mentioned a figure there of nearly 1,500 children-----

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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Yes, nearly 1,500.

Mr. David Walsh:

-----on a long-term waiting list, which is an incredible indictment really. We need to chip away at that one by one and not just those 1,500 but the next 1,500 in Carlow coming up behind that. It is a large task, but we are trying to get the policy and resource pieces in place that will allow us to do that. CAMHS would have had a long history too of being underresourced in CHO 5-----

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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Yes.

Mr. David Walsh:

-----but, the chief officer there has worked very hard over the last 12 months in particular to build those resources.

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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She has.

Mr. David Walsh:

It is showing a commitment to do things better. Some of the things we need to figure out - and it is all now under the same Government Department in the Department of Children, Equality, Disability, Integration and Youth - is the relationship between what we do, what Tusla does, what the schools do and what we demand of each other. We have reservations about some of the assessments schools believe they need to make decisions about kids. We do not necessarily think they need them. They just need to go on the presenting conditions. That is something we are working with the Department of Children, Equality, Disability, Integration and Youth on to try to figure it out in a better way.

On the capital plan, I understand that capital funding is within the plan. I do not know the details-----

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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It is, but it is the timescale of getting children with disabilities out of a prefab and into a build.

Mr. David Walsh:

Yes.

Michael Moynihan (Cork North West, Fianna Fail)
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A vote has been called in the Chamber and we have our last member, so the officials might come back to Deputy Murnane O'Connor on any outstanding points in writing.

Before we adjourn the meeting there are a couple of points I want to make. Has the HSE disability managers in each of the CHOs? Some people have said to me the disability manger post in one of CHOs is not filled at the moment. Is there an appointed disability manager in each of the CHOs? On the services, both Tusla and the HSE see the capacity within the system. Are they actively engaging with the service providers, the section 38 or 39 organisations in how to expand? Up to 2007 or 2008 there was a huge amount of residential facilities and units built or bought by section 38 and 39 organisations under the capital assistance programme from the Department. That has almost ceased to operate at the moment. That funding is there and is accessible. All of us public representatives daily meet people looking for residential care and experiencing different family challenges and the services are not there. That then comes to a crisis point where the care is no longer available and there is a crisis created.

We will have to conclude the meeting but I would appreciate an update from both Tusla and the HSE about their engagement with service providers in respect of engaging with them and asking them to go to look at the various schemes that are available to access funding for it. We need clarity on the issue of the disability managers in each of the HSE CHOs and we need uniformity of service. One service provider that is working with two CHOs says the attitude in one is completely different from the other. When it is looking for funding, it is easier to get it from one CHO than the other. That is not acceptable. I go back to the Mental Health Commission and CAMHS. What is the blockage here? I was led to believe at the start of the meeting that the legislation was in place for the commission to take over CAMHS and youth mental health services. Maybe this could be clarified.

Some people who have worked in the private sector as OTs and speech and language therapists, move to the HSE and then they leave-----

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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They do.

Michael Moynihan (Cork North West, Fianna Fail)
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-----because they are so frustrated with the culture and the attitude in the HSE and the various schemes on which they work. These therapists want to see three, four or five patients, including kids, and the next thing is, somebody tells them not to show colleagues up. They are only allowed to see three patients a day, whereas in the private sector, they would have seen ten. Can that attitude be rooted out? I have experience of discussing it with an awful lot of OTs and speech and language therapists and they say the culture within the HSE is to do as little as possible in terms of seeing kids. We need to know where the challenges are there. Unfortunately, I cannot stay for the answers. I would love to because there are many interesting questions. It is a challenging service that both Tusla and the HSE provide. We look forward to their engagement but we are here to challenge on behalf of people with disabilities and to try to make the system better. I thank one and all and adjourn the meeting until next Wednesday.