Dr. Austin O'Carroll:

First, to go back to the idea of bad choice, I do not see it that way because when one is living in poverty, in particular if one comes from a dysfunctional family, we see drug addiction as the way to treat the actual trauma. In a way, it is not a choice at all when all one's friends are on drugs, one does the same. In a way we need to get away from the idea of bad choice because the addiction is created by poverty. That is the causation.

I agree we have come a long way, but I wish to address two issues, one is methadone and the other is the provision of primary care services to the homeless. There is still a problem down the country. We have many people coming to us who become homeless specifically to get onto methadone. We have started over 500 people in the last four years on methadone through our homeless services, where we treat them in the community. A significant proportion of them have come up from the country. It relates to Ms Dolan's point about the lack of services down the country. I see that all the time.

I will outline two stories. One story turned out really well. It is about one of those people on the canal who was in a tent. The person had been homeless for over a year. We started them on methadone and within six weeks they had stopped living in the tent, moved into accommodation and stopped using heroin. That was fantastic. The other story is about a young girl who came up from the midlands. She was a mother who came up to us to get onto methadone because she could not get it in her local area. She went to stay in a hostel, got onto methadone with us and did very well. She moved back to her home but came up to us for her prescription, which was crazy. When she came up she had to stay in a hostel and one night she was violently assaulted there and ended up back on the streets because of the depression relating to the assault and died three weeks later from an overdose. If she had got treated down the country she would not be dead.

We have had two people die on our waiting list for methadone in the past six months. People do not realise it but more people die from drug-related deaths than from suicide or car accidents combined. It is the biggest killer of young people and is much more dangerous than diabetes, as Dr. O'Reilly indicated. The huge gaps in drug services down the country are a significant issue.

The other issue relates to what has been said about rural areas. The Chairman referred to a team for homelessness. To be fair to the HSE, it has funded a number of our services and we reach over 50% of the homeless population with primary care services. The HSE is funding many services that are getting out there to the people. The problem is that when there are so many chaotic people, it is very hard to adapt a general practice service to respond to their needs. It is a case of achieving a fine balance. One does not want people to get dependent on our services because that might capture them and keep them in homelessness, so one wants to capture them and hold them, like a safety net while they are in homelessness but as soon as they get into accommodation they would get back into the mainstream services. We need to maintain those flexible services while still allowing the route back into homelessness. Our problem is - this comes back to the query about getting a primary care team for homeless people - that we still have to use other primary care services, for example, physiotherapy, counselling and occupational therapy in the mainstream and they give out appointments. Homeless people do not keep appointments. They do not have home addresses to send the appointment notices to; they have chaotic lives; they do not have diaries; they do not have time or transport and they do not keep appointments. It would be extremely useful to get into homelessness services those primary care health professionals that we cannot access. It is the primary care Safetynet team that captures people and it could be hugely expanded.

There is a gap in particular in the area of mental health, as we have indicated several times. There are psychiatrists who work in homelessness but they deal only with pure schizophrenia or manic depression, the pure psychoses, which comprises one in five or one in six homeless people. They will not deal with people who have drug addiction. They say that is the role of psychiatrists who deal with drug addiction, but the problem with the psychiatrists who deal with drug addiction is they deal with people who attend the addiction centres. Only yesterday Dr. O'Reilly and I had a meeting about this with doctors and nurses who are frustrated because they cannot get mental health services for people on the ground. There needs to be a dedicated mental health team which works with homeless people whether they have a drug addiction or not. That needs to be urgently addressed. I know the HSE is trying to do that because it recognises the problem but it has been trying to do it for several years. It needs to get the funding resources in place to address the issue.

In response to the question of bedsits - I know the issue has been repeated over and over - I do not know anywhere that the private sector has addressed the issue of homelessness.

The Deputy asked about comparisons across other countries. I am sad to say I am in a thriving business. It is terrible to say, but the reason it is thriving is because of the lack of responsibility being taken for social housing by Government. I agree that it is not about providing vast estates of social housing. In the Netherlands, 33% of housing provided is social housing but it is much more integrated amongst the community. It is not set up in vast housing estates which concentrate many social problems into one area. It is really important to get that point across. It would be great if really nice, wonderful apartments which have a bed and a living space could be provided but I fear that the reality is that once bedsits are allowed the previous terrible situation of having horrific bedsits will return. When I used to do house calls I would see people living in appalling states. It is not the private sector but the public sector that needs to get moving.