Mr. Peter Hughes:

I thank Senator Freeman and the committee for the invitation to appear before it.

The Psychiatric Nurses Association represents the vast majority of nurses working in the mental health services. Unfortunately, the number of nurses working in the CAMHS is diminishing. It is difficult to recruit, particularly in the CAMH services.

I will highlight our concerns regarding the child and adolescent mental health services. The inadequacies and underinvestment in the current provision of CAMH services is something to which my union has consistently drawn attention and today's consultation should help in addressing the many gaps in CAMH services that exist nationwide.

In 2006 the Government policy on mental health, A Vision for Change, was published outlining a ten-year plan for the provision of mental health services. Chapter 10 of that widely welcomed strategy outlined the recommendations for child and adolescent mental health services. Some of the key recommendations included the provision of two multidisciplinary teams per 100,000 of population, one liaison multidisciplinary team per 300,000 of population and one day hospital per 300,000 of population. It went on to state that urgent attention should be given to the completion of the planned four 20-bed units in Cork, Limerick, Galway and Dublin and that multidisciplinary teams should be provided for these teams. This would have resulted in 100 beds nationally.

Most importantly, the strategy in A Vision for Change included a provision for an evaluation after five years to assess the progress in the delivery of child and adolescent mental health services and whether it is meeting the needs of the population. That did not happen and 11 years on, one must question the commitment to the recommendations in A Vision for Change. The Psychiatric Nurses Association, PNA, in partnership with the Royal College of Surgeons in Ireland, RCSI, published research last year on the implementation of A Vision for Change in the adult mental health services ten years on. The results were stark. Among the findings were that 60% of beds were closed yet only 30% of the recommended community services were put in place, and there were no 24-hour crisis intervention services as recommended.

We are currently conducting a second phase of research in partnership with the RCSI on the specialist elements of A Vision for Change, inclusive of CAMHS. Early indications suggest that 37% of the recommended multidisciplinary teams are operational as outlined in A Vision for Change, most of which do not have a full team, while 53% of the liaison services are in operation.

There are now 48 operational beds out of the 100 beds which were recommended. This research will be concluded towards the end of the year.

The population of children nationally is expected to increase by 8,500 between 2016 and 2017, which is consistent with the percentage increase annually over the past decade. This projection, coupled with the expansion of the free GP scheme, will create an additional demand on child and adolescent services. I refer also the appalling situation of young homeless children who currently live in hotels, guest houses and short-term accommodation. Not only does this increase the level of mental distress for those involved but transient situations also complicate the follow-up for these children as they are transferred from one CAMHS service to another.

According to the mental health division operational plan 2017, there are 74 multidisciplinary teams. A Vision for Change recommended two teams per 100,000, which would equate to approximately 94 teams. This is a shortfall of at least 20. In the greater Dublin area alone, only 50% of the recommended multidisciplinary teams are operational. Again, these are not full teams. There are four day hospitals nationally. A Vision for Change recommended one for every 300,000. This equates to 15 day hospitals, meaning we have a shortfall of 11. There should be 100 beds nationally but there are only 48 operating currently due to staff shortages, particularly that relating to nurses. There are 20 beds in Cork but the unit only has the capacity for a maximum admission of 11 children. As the speaker before me mentioned, this is down to shortages of consultant and nursing staff. St. Joseph's unit in Fairview has 12 beds, of which only six are operational due to both nursing and medical staff shortages. The promised Limerick unit never materialised. The 20-bed unit in Galway appears to be fully operational. In the past month, the new purpose-built 22-bed unit in Linn Dara, which only opened 18 months ago, has closed 11, or 50%, of its beds due to nursing shortages. The unit has only 50% of the nursing resources required and the 11 beds were closed despite the fact that 20 children were awaiting admission. The consultant psychiatrist in the Wexford service is on leave and there is, therefore, no consultant cover in that area.

We know all too well that the net result of these bed closures and the under-provision in child and adolescent services is to further increase the unacceptable admission of children to adult mental health units. We witnessed a stark example of this just last month with the admission of a 16 year old to the adult mental health unit in Waterford. Adding to the trauma already experienced, this child had to spend the night sitting on a chair. As recently as last night, a 17 year old was admitted to a chair in Kilkenny adult mental health unit. Just over a week ago, another 17 year old in Kilkenny was admitted and remains on the unit. Both Waterford and Kilkenny are operating above capacity with the result that children are being admitted to chairs. To say 11 years after the publication of A Vision for Change that this is unacceptable is an understatement. CAMHS are in crisis and, as outlined, the provision of services is deteriorating rather than improving. There were 74 operational beds two years ago but 26 fewer beds are operational now.

Children and parents are being let down by the non-implementation of the policy and the lack of commitment or urgency in addressing the crisis yet we have known for 11 years what needs to be done to address the crisis. As a matter of urgency, the 100 beds recommended must be provided and staffed in order to provide quality therapeutic care and prevent further admissions of children to adult units. The number of community mental health teams must be increased as recommended and they need to be fully staffed and expanded to provide out-of-hours, home-based services. The criteria for clinical nurse specialists is too stringent and must be adapted in the short-term to facilitate an increase in applicants. There are approximately 20 unfilled clinical nurse specialist posts nationally, mostly due to insufficient applicants as the criteria is too strict. The recommended 15 day hospitals must be provided. The full implementation of these measures will only take place through a substantial increase in the budget for mental health services, which currently stands at 6.4% of the health budget.

Bizarrely and probably only in Ireland, we have witnessed a situation where, despite the growth in the demand for mental health services across the board, there has been a steady reduction in the mental health budget as a percentage of the overall health budget. According to A Vision for Change, the budget was 13% of the health budget in 1984, 10% of the health budget in 1994 and 7.1% of the health budget in 2004. The commitment to mental health services has diminished in each decade but the demand has never been greater. It is little wonder that the previous Taoiseach, Deputy Enda Kenny, admitted in the Dáil on 23 May last that mental health services have been neglected for over 30 years and were, as he put it, the Cinderella of many HSE Votes and Department of Health Votes. Looking at the mental health budget, it is sadly hard to avoid concluding that A Vision for Change was used as a cost saving measure on the backs of those with mental health issues.

Too often, we have seen the closure of beds with a paltry investment in community services. We struggle to provide vital services while trying to manage a severe shortage of psychiatric nurses, largely because our highly-skilled and committed nurses are being forced to leave the Irish health system for better pay, terms and conditions in the private sector, the UK, Australia and Canada, to name but a few of the market contenders. Who can blame them when there is a consistent failure to address pay and conditions in a realistic manner? That is the only realistic solution to stop the haemorrhage of our nurses to other countries and encourage those who are abroad to return. Something similar can be said about the medical profession also.

I thank the committee for the opportunity to outline briefly the extent of the ongoing crisis in child and adolescent mental health services which we know is impacting severely on parents and children. I assure the committee that the PNA is determined to see the issues in child and adolescent services addressed before they deteriorate even further. We would welcome the committee's support in achieving the provision of a properly-resourced and staffed CAMHS which meets the needs of children, families and communities nationally.