Dr. Shari McDaid:

I will respond to the questions one by one.

Deputy Kelleher started off by talking about funding and the fact that there has been investment. The challenge has been that, despite allocations of funding at budget time, the issues with retaining staff in the service and the slow process of recruiting new staff have meant the numbers have just not increased; that is the bottom line. It is a case of a boat with a hole in it wherein one keeps trying to throw the water out. The services are leaking staff all the time. This is the case because there are attractive retirement packages. The age profile of the nurses in the mental health services is such that a generic provision meant to lower the overall number of health service staff has affected mental health services much more heavily than others. This has not been dealt with. We are now at a point where, for the first time since 2006 and the publication of A Vision for Change, we are facing severe difficulties in providing enough nurses to staff acute wards and provide community services so people do not end up in acute wards. I refer to services such as day hospitals open seven days a week. These have to be staffed by nurses. If we do not have enough nurses, we cannot provide the crisis support required to prevent people from ending up in hospital. Right now, we are really in danger of moving seriously backwards with the agenda in A Vision for Change because of the difficulties with staffing.

Interestingly, the difficulty employing consultants is part of the reason CAMHS is not doing as well as it should be. It has had severe difficulties in recruiting specialist consultants to fill teams and man inpatient wards.

With regard to the admission to wards of children and adolescents, we have actually gone backwards this year. This is of severe concern. Steps were taken to increase the number of beds. There was a maximum increase of approximately 56 beds earlier this year. This then decreased by ten over the summer, resulting in fewer than had been anticipated. In the context of A Vision for Change, there should be 80 beds. This was based on a smaller population so we really need more now. We are in danger of moving backwards rather than forwards.

With regard to the counselling in primary care service, it was asked whether difficulties in meeting demand mean people end up in hospital. That is a possibility although the service is really geared towards people with mild-to-moderate mental health difficulties, not those in a severe crisis. The intention is that, by catching people early, they will not end up needing specialist mental health services and potentially more severe treatment down the line. It is so important that general practitioners have a place to refer patients to because we hear time and again that people have felt over the years that all they are offered on going to their general practitioner is medication. They do not necessarily want medication alone; they want other types of supports. The service needs to be built up much more and we need to consider creative solutions. If we do not have dozens of psychologists available, we need to consider creative solutions drawing on the expertise of NGOs and other types of providers so as to meet the need.

The reality in Ireland is that there are very strict referral criteria for child and mental health services. Basically, a general practitioner must make a referral. There are some sound clinical reasons for that. This is understandable but, in recent work we did examining procedures, we learned there is more flexibility in other jurisdictions, including the United Kingdom and Australia. Therefore, we believe there is scope for more flexibility, as in allowing concerned teachers and social workers to have easier access.

The Jigsaw services comprise a positive development. I refer to open community centres that young people can go to. They are more youth-friendly than other services. They are not medical or general practitioner surgeries but centres to which people can go to talk to somebody if they are concerned about their mental health.

Those seem to be working well and there is investment in rolling them out more widely this year.

I thank Deputy Ó Caoláin for his kind words about mental health reform. We work hard to essentially draw together the concerns, issues and good practice around the country. We will keep trying to do that. I will speak to the homelessness issue and the relationship between the housing crisis and what might be happening in mental health services. One of the concerns drawn to our attention this year in particular is the difficulty in being able to discharge people from acute wards because of a lack of housing availability. It is shocking that despite a major push towards community-based mental health services, we might have people ending up in an institutionalised setting in an acute ward longer than they need to be there because there is no appropriate housing option in the community. That concern arises because of the housing crisis.

We were asked if we had any information on where the 2015 allocation will go but we do not. It is correct that this was not specified by the Minister of State, Deputy Kathleen Lynch, in the joint announcement about funding. We expect there should be some information about that in the HSE's national service plan or the mental health division's operational plan. There is still a major shortfall to be made up. We were asked about the negative consequences of the €15 million shortfall and I can allude again to staffing shortfalls. We are not in a position that we have so many staff in mental health services that we cannot think of what to do with more; we are in the opposite position, as services are under strain. Even with multidisciplinary staff, although it is positive that the proportion has doubled, the numbers of staff are still well below needs according to A Vision for Change. There is plenty of scope for further investment.

There was a question about the Mental Health Commission, which has been impacted by the moratorium to the extent that it was having difficulty filling some of its inspection and other senior management posts, meaning it has been difficult for it to fulfil its functions, particularly in having multidisciplinary input into its inspections. We want to know that the Mental Health Commission can fulfil its remit, as it is the main means of accountability for how well mental health services are fulfilling legal obligations.

I thank Senator van Turnhout for her kind words about our organisations. She expressed concern about the absence of an independent reporting mechanism. I agree that we are in a position without regular annual reporting, which is against the recommendations of A Vision for Change, either internally by the HSE or externally by an independent body. That puts us in a very difficult position. No voluntary organisation has access to the information that might be obtained by having an official mechanism for reporting. I agree that there is a need for a robust but efficient reporting mechanism, which should not be overly onerous on services but which should give the required information. I did not allude to a difficulty in my statement but it is mentioned in successive pre-budget submissions. We asked for an information system for mental health services over previous years and were told initiatives were under way to improve the position. There has been a modest improvement this year, with some activity data for the adult mental health services that we have not had before but it falls far short of what is provided for the child and adolescent section.

We are very disappointed the development of an information system is not progressing at a better pace as we simply do not know the level of need for mental health services. It is very significant that we have not had a national survey on the psychological well-being of the population since 2007. Right through the recession we have not had a data source on the national levels of need. It is very welcome that the Royal College of Surgeons in Ireland has produced data on child and adolescent need which is pointing to the higher levels in Ireland, and we can only suspect what may be the higher levels for adults as well, given the economic strain that people have been under. Both of those elements are very important.

Why are children still being admitted to adult wards? We have spoken about the reduction in the number of beds and there is also a need for good training for staff. The HSE's restriction on training has had a very direct impact on the adequacy of the inpatient child and adolescent mental health services. Staff who do not feel equipped to respond to children with very complex needs or behaviour will resist children being admitted to wards. We need to shift towards investing in training for staff so they can respond appropriately. Interestingly, that extends to services where we need training in how to work with adults with difficult behaviour as well so we can have less use of seclusion and restraint.

We were asked if non-governmental organisations, NGOs, should see more investment in order to provide awareness training. There is a need for a combination of public sector investment and work with NGOs. A partnership approach is probably correct and I would like to see much deeper investment in community development initiatives for mental health and well-being. Sustained community development work will bring about a shift so that fewer people will develop mental health difficulties at an early stage.