Dr. Matthew Sadlier:

I am Dr. Matthew Sadlier and I am a consultant adult psychiatrist. I am here to represent the Irish Medical Organisation, IMO, and to set out the views of doctors in Ireland on the problems facing child and adolescent mental health services. The IMO is the representative body and trade union for the medical profession and represents all doctors across all grades.

Through written submissions made to the committee and those made to it during last week’s hearing, the committee will be aware that mental health services for children and adolescents in Ireland fall far short of what is needed and that we are failing young people and their families. In many ways mental health awareness has never had a higher profile, with sufferers encouraged to seek help. However, while as a society we might encourage our young people to access the help they need, at present we have neither the capacity nor the staffing in place to adequately respond to those requests.

Funding for mental health care in Ireland remains low. In the HSE's service plan for 2017, funding for mental health services made up just 6.1% of the HSE's total operational budget. This is a far cry from the 8.24% of total health fund spending that should be directed to mental health services, as set out in A Vision for Change in 2006. We have seen the percentage of total health budget for mental health decrease from 13% in 1984 to 7.3% in 2004 and to the current 6.1%. By way of contrast, many other western European health systems, such as those in France, Germany and the United Kingdom, spend approximately 10% to 11% of their health budgets on mental health services. This chronic underfunding has manifested in a failure of State agencies to build the necessary capacity to provide adequate mental health services to children and adolescents.

The IMO recognises that good patient outcomes are most likely if patients have timely access to advice, assessment and treatment, but the latest figures available show that CAMHS are still far below the level of capacity recommended. Just 67 child and adolescent mental health teams are in existence out of the 95 teams recommended in A Vision for Change for the population of the country. This means that each team is forced to serve a larger population, creating additional pressures on staff and, inevitably, longer waiting lists. Just 66 CAMHS inpatient beds are in place, which is far less than the 100 beds which were required in 2006. Since 2006, there has been a population increase of approximately 216,000 in the age group of less than 18 years of age. This is a rise of 21%, so the need for beds is even greater than it was in 2006.

Furthermore, inpatient beds are available only in the major urban centres of Cork, Dublin and Galway, often placing treatment options far from the homes of patients in other areas of the country. For example, no inpatient beds exist in the country's north west, south west or midlands, nor are there beds in the country's third most populated city, Limerick. Where referrals are required for patients in these regions, they travel to Dublin, Cork or Galway, which puts additional strain on both patients and families. Our membership has reported that facilities are often unsuitable for the provision of care to children and adolescents.

The IMO has identified deficiencies in service provision nationwide, with specific problems identified in the CAMHS teams in Mayo, Roscommon and Wexford. Pronounced staffing difficulties also severely hamper service provision. According to A National Model of Care for Paediatric Healthcare Services in Ireland, currently CAMHS teams in Ireland have approximately 50% of the staffing recommended by A Vision for Change. This limits severely the number and range of therapeutic interventions that each team can provide. Many CAMHS teams operate with as little as one third of the complement of staff required under A Vision for Change. Often teams nationwide share staff members, thereby rendering the full extent of under-staffing ambiguous as the same individual may be reported as being a member of more than one team. This is creating a virtual postcode lottery, whereby the range of services is dependent on a patient’s address rather than on need.

In the absence of adequate primary care teams with allied mental health professionals, such as psychologists and speech and language therapists, general practitioners, GPs, often have no option but to refer patients to secondary specialist services instead of being able to manage some patients in the community setting. Chronic under-staffing and a lack of capacity, despite the recommendations of the Mental Health Commission, have resulted in 68 children being admitted to adult psychiatric units in 2016, representing approximately 18% of all child admissions. At the end of March 2017, some 51% of referrals to CAMHS were waiting over three months for an appointment, demonstrating the inability of the existing staff to treat patients in a timely manner.

Mental health services, indeed most health services in Ireland, encounter major difficulties when attempting to recruit personnel, leaving many health services in Ireland critically under-staffed. Recently, the IMO has heard complaints from doctors being forced to work hours far above legal limits, due to severe under-staffing. This problem has been particularly identified in the CAHMS in north Cork, where three non-consultant hospital doctors have been forced to provide 16 hours each of on-call cover each week day and 24 hours of on-call cover each weekend on top of their 39 hours of weekly commitment. In responding to calls from the IMO that this practice cease and that correct staffing levels be attained, the HSE stated that it did not believe it would be possible to alter the current work practices within the service. It referred to "significant difficulties recruiting suitably trained personnel, at local and international level, which is having a significant impact on the quality and timeliness of service provision".

Problems such as these are not restricted to services in Cork, however. Waterford, for example, has funding for three child and adolescent consultant psychiatrists but has only been able to fill one and a half of these posts. In north Tipperary and west Limerick there are no non-consultant hospital doctors and no consultants in training on the CAMHS teams. It is little wonder that the health services in Ireland experience pronounced difficulties recruiting and retaining medical staff when both remuneration and working conditions lag significantly behind those available elsewhere in the English-speaking world, with which we largely compete for medical staffing. Independent research on the emigration of health professionals from Ireland has found that "much recent emigration has been driven by dissatisfaction with working conditions in the health system and uncertain career progression opportunities, aggravated by austerity-related staff reductions, salary reductions and taxation increases". This research has also indicated that the overwhelming majority of those who leave do not plan to return to Ireland and experience superior working conditions, training and professional opportunities abroad. Simply put, no solution can be found to the staffing issues within the mental health services unless action is taken to resolve the current recruitment and retention crisis among health professionals.

Additionally, structural issues must be addressed. Sufficient CAMHS inpatient bed capacity must be provided, in appropriate locations, to ensure that all children who require such care can receive it and thus end the practice of the inappropriate admission of children to adult psychiatric units. General practitioners must also be provided with the necessary resources in their primary care teams to manage patients presenting with mental health problems, without recourse to secondary care. Finally, the confusion regarding discrepancies in the definition of a child between physical and mental health services, which leads to the confusion we have heard about today, should be resolved. The IMO calls on the committee to recognise these issues as central to remedying the problems facing child and adolescent mental health services and to recommend that immediate remedial action is taken to address these issues.

I thank the committee for its time this afternoon and both Mr. O’Dowd and I will be happy to answer any questions.