Dr. Brendan Doody:

I thank the committee for inviting me here today. I welcome the opportunity to speak further to the submission I made on behalf of the consultant child and adolescent psychiatrists who work in the four HSE inpatient facilities. I will address the demands placed on inpatient services and will reflect on the goal set out in A Vision for Change that all young people under the age of 18 should be treated within age-appropriate facilities.

It is important to remember that prior to A Vision for Change, child and adolescent mental health services were organised primarily for children under 16. A Vision for Change set a challenge in extending the age threshold to 18. As we were starting from quite a low base to begin with, this was placing an additional demand on services. A significant investment in child and adolescent mental health services was thus needed at both community and inpatient levels. The recommendations for inpatient services, referred to earlier, called for a total of about 108 inpatient beds. It was also recommended that a proportion of those 108 beds be dedicated to the more specialist provision of a secure inpatient facility and the development of a dedicated inpatient eating disorder service. In 2007, there were just 12 inpatient beds available for the admission and treatment of young people under 18. Although there has been great progress over recent years, we are still not at the recommended level as set out in A Vision for Change.

The purpose of inpatient admission is the assessment and treatment of young people with the most severe mental health disorders through the provision of specific evidence-based treatment plans. There is a goal of achieving the earliest possible discharge in order that the young person is an inpatient for the shortest time possible. There must be an adequate number of beds available for access to be provided in a timely fashion. However, that is very difficult when the demand for inpatient admission exceeds the availability of inpatient services. The number of beds within the public system has now increased to a total of 76. However, not all the beds have been operational due to staffing challenges in respect of nurses and consultant psychiatrists.

I can speak to this matter as clinical director of the Linn Dara unit where it has been necessary to close a number of beds temporarily because of nursing staff shortages. That was a very difficult decision to have to make, and it was made when it was not possible to continue to have the beds open. As a service, it is our priority to ensure they are reopened as soon as possible. I very much concur with previous speakers on the reasons for staffing difficulties. They have to do with a range of issues including pay, career progression and, particularly in certain parts of Dublin, the cost of living and accommodation. Within our service, most of our nursing staff travel quite a distance to work. When posts become available closer to where they live, it is not surprising that they take up those positions. As we increase and develop community services, we often draw staff from other existing services.

Over the past ten years approximately, a number of developments have taken place in respect of inpatient services. Since 2010, there has been a 40% increase in referrals to community child and adolescent mental health services. This is mirrored by the increase in admissions of young people under the age of 18 to inpatient beds. In 2007, there were 364 admissions and by 2015, the figure had increased to 503. The number of young people admitted to HSE and HSE-funded units over that time increased from 78 to 312 in 2016. While the number of children accessing beds in age-appropriate inpatient settings is increasing, so is demand. If we are to achieve the goal of having the minimum number of children requiring to be admitted to adult facilities, we have to adopt what I would describe as a whole-systems approach. It is about ensuring we have adequate resourcing of services at primary care level, adequately resourced teams in community services, and the option of intensive day services as an alternative to admission.

As the units are regional, often the young person may be admitted to a unit quite a significant distance from where he or she lives. If we have well-resourced services in the community, this may reduce the need for admission but, more importantly, it will also facilitate earlier discharge. When there is admission, there is obviously a very intensive treatment and support programme available to parents. Families find the step down to community services to be quite steep. Really it is sometimes very difficult for very stretched community services to meet the needs of these families, a factor which may prolong admission unnecessarily. Children who are admitted to inpatient settings may also have complex needs. Some delayed discharges may be influenced by deficiencies in other services, for example, community child and family services or the specialist disability services we discussed earlier. There is a need to address resourcing within community services and to build up capacity at all levels. Then we need to look at the inpatient setting.

We must address the problem of beds that have been provided not being fully operational and available. The reasons for this clearly come down to issues of staffing. We also need to undertake a needs analysis in respect of the number of inpatient beds that are required. The Vision for Change report recommended that a review take place in this regard. Comparison of bed numbers is often made only with the United Kingdom.

To make a comparison with other countries with populations equivalent to the population of Ireland, Norway has a slightly larger population than Ireland but has more than 300 inpatient beds. Interestingly, its workforce in child and adolescent mental health services, CAMHS, numbers more than 3,000, whereas the total workforce in specialist child and adolescent mental health services in Ireland is 800. In addition, Finland, Germany, Denmark and New Zealand recommend inpatient bed provision significantly above what is currently provided here.

A review must be undertaken to determine the need for inpatient beds. We know secure inpatient facilities will come on stream and specialist inpatient beds are being developed as part of the new paediatric hospital. Having been involved in building and commissioning an inpatient unit, I know that a long lead-in time is needed to bring inpatient services online because the facilities must be commissioned and built and staff need to be recruited. We face challenges recruiting staff for the new unit in the new paediatric hospital.

To be able to provide the best inpatient service, we must be able to provide the best possible service at all levels. The key must be that children access a service at a level that is most appropriate to their needs and do not have to attend specialist or inpatient services where this would have been unnecessary if the appropriate intervention had been available at another level.