Professor Brendan Kelly:

I thank the committee for asking me to appear before it. I am a general adult psychiatrist, not a child and adolescent psychiatrist. I will speak a little about some of the knock-on effects of the state of the child and adolescent mental health service in Ireland. I will start with a fairly typical case I might see in a hospital emergency department. For example, it is not uncommon to see a 16-year-old or 17-year-old boy or girl who has self-harmed and is in need of some kind of crisis intervention. Very often, admission to a facility may be helpful in the sort term. As an adult psychiatrist, I try very hard to meet the need of a person and family. For the most part, there is no admission bed available in the child and adolescent mental health service so it is very common for us to spend many hours on the telephone looking for a child and adolescent bed while trying to put in place a plan. Often I would have a very distraught and desperate family seeking a solution when it is the first time they would have encountered this kind of issue. They will need something. Those are the circumstances in which, occasionally, a child is admitted to an adult psychiatry unit. The point I make is that this is not something that is ever undertaken lightly but rather it is done in extreme and exceptional circumstances because there are many down sides to it. Very often it is done at the request of a very distressed family.

This is a very high-risk group, particularly adolescents. For Ireland as a whole, the rate of suicide has fallen over the past six years by approximately 19%, which is a very significant national reduction. There is an exception, particularly in young males aged between 15 and 24, where the rate has actually gone up. There is a counter-trend going on and this is a very high-risk group. We also know children and adolescents account for approximately 25% of the population, and as far back as 2005, the College of Psychiatrists of Ireland pointed out that the mental health budget for children and adolescents is approximately 5% of the mental health budget. There is a disproportionate distribution of budget in this respect.

I am keen to focus on solutions and I share very much many of the points made by the previous speaker about the availability of psychological therapy and particularly psychotherapists. When we encourage people to speak, there should be someone for them to speak to. Many of these people come from settings where there may not be people to speak to and it is very important that is provided.

In terms of mental health policy, the long-term goal should be to implement A Vision for Change, the 2006 policy, which must be altered slightly and upscaled. We now have a population of 4.7 million people. The policy is quite good and with some tweaking it will be good for some time longer. However, we need a short-term solution as well because the situation is exceptionally difficult now, particularly with the recent closure of some of the child and adolescent inpatient beds owing to staffing problems. This must be addressed. The admission of children and adolescents to adult psychiatry units should cease, and there is no doubt about that. The question is how can this be achieved in a safe, sustainable fashion and how quickly can it be done.

Some adolescents, such as 17 year olds, might present with the problems of adults. Some of them can be as large as adults and present with mental health problems like adults and admission to an adult unit might be indicated. Even then, however, an adolescent unit that examined their educational and broader needs would be preferable.

The key at present is retention of staff, in particular nursing and medical staff, as well as expansion to other disciplines. There must be a programme of meaningful incentives for staff to be recruited and, even more importantly, retained. Experienced staff are leaving the service owing to difficulties with retention. The incentives must be tailored and meaningful. This is not always or even chiefly about money for medical or nursing staff. It is to do with conditions of work and, in particular, career progression and an assurance about a career progression pathway. In the short term, a comprehensive staff recruitment and, especially, retention programme is required to try to operate the resource we already have. In the long term the implementation of the A Vision for Change recommendations is required, slightly changed and increased to account for a population of 4.7 million people.

The importance of this cannot be overstated, in particular the very acute plight of adolescents who end up in emergency departments following episodes of self-harm or other types of disturbance. As an adult psychiatrist I never admit such a person to an adult psychiatry unit unless all other options have been comprehensively examined and we have a person unable to go home and a family unable to deal with an outpatient option. However, there are times when it is necessary, given the circumstances. I urge that both a short-term and long-term approach be taken. That is all I recommend to the committee.