Ms Anne O'Connor:

The Deputy has asked many questions, some of which I will address and I will then ask my colleagues to address the others. In regard to agency staff and recruitment, which we addressed last week, we do have agency staff and we try to recruit them but, unfortunately, they do not all want to work. The flexibility that is granted by working as an agency staff member is very different. We have tried to offer contracts to agency staff but not all of them want to take them up. There is no issue around funding. We have to keep our services operating and so we staff what we can with existing staff and we then seek to recruit agency staff. It is not only the HSE that cannot recruit as agencies are now also struggling to get staff, which is something not previously experienced. I referenced at our last meeting that we had to close beds in a CAMHS unit in Linn Dara. The reason this is so bad this year is because the agency could not get staff either. There is a general shortage of the staff we need. This has been the experience not only of the HSE, but across agencies and our funded partners over the past year to 18 months. There is a wider recruitment issue that is hitting the health sector because we are operating in a global international market for staff. It is worth noting - this was referenced in one of the responses given earlier - that in Ireland we have very fairly highly trained mental staff. Not all countries specifically train nurses in mental health. Our nurses are, therefore, very attractive to other jurisdictions. Only about three or four countries have dedicated mental health training for nurses. Our nurses go abroad. There are massive recruitment campaigns going on in the UK that are offering very attractive packages which are very difficult to compete with.

In regard to packages and pay scales, these are not within our gift. We were involved in the Bring Them Home campaign last year, which was an international nursing recruitment campaign. We got a very small number of nurses arising out of this very big initiative that involved representative bodies, the HSE, the Department of Health, etc. There was a package agreed as part of that campaign but it did not cut it for us. To be honest, some people would not come home for what they were being offered. Also, the HSE is locked into the public pay frameworks and it cannot decide to pay anybody outside those agreements. This is an issue we work with every day, and it is broader than mental health and the HSE. I hope that answers the Deputy's questions on the agency and recruitment issue regarding the conditions. I also point out that when we were having difficulties recruiting consultants, we worked with the Public Appointments Service to survey consultants abroad to determine why they were not coming back to Ireland. The feedback we got was that they were all aware of the posts that were available. There was no lack of information in that regard. It was not just an issue of pay but the environment in which they would be required to work, rosters and lack of facilities, etc. It is a bigger issue that just pay.

Mr. Ryan will respond later on the seven day services and out-of-hours service because he is leading in that area and Mr. Dodd will respond to the questions on dual diagnosis and the accident and emergency aspect. In terms of primary care, most mental health is dealt with in primary care. We could argue about whether there is sufficient capacity in primary care to support GPs. We know that capacity does not exist from a psychology perspective. It is for this reason that we are investing in the 120 assistant psychologists for under 18s. There are not enough avenues for the GP to take and GPs say that they are obliged to refer people to specialist mental health services even though they know that, for example, counselling might be what they need. The National Counselling and Primary Care Service operates for people with medical cards only. Anybody who does not have a medical card does not have access to that service. We fund agencies to provide different kinds of counselling on our behalf, to which there is variable access. I mentioned last week that we are looking at a national initiative around improving access to psychological therapies and talking therapies. We are bringing in a clinical lead to do that piece of work. We have a variety of different types of counselling across services. I accept that is an inequity in different areas in that there are some types of services available and not others. We want to have a standardised approach to how we do the talking therapy side of things. We are also conscious that we need to develop services in general in primary care because it is not all about counselling. For example, with young people it might be about speech and language therapy, occupational therapy or something that is not a mainstream mental health requirement.

In regard to homeless people, we have specialist services to meet need in this area. As mentioned on page 29 of the document on homeless services, which was provided to the committee, there are specialist teams for people with severe mental illness, one on the north side of Dublin and the other on the south side. There is a similar service in Cork and another in Waterford. These services are for people who have long-term mental health conditions. We know that GPs deal with people but there is a gap in the service for people who have become homeless and do not have a severe mental health illness but are at risk of developing it. We are conscious of that gap and we are well advanced in our work with the NGO sector and other services on putting in place a stepped care model to support people with mental health illness. We are looking at how we can provide a more aggressive and assertive outreach model to people who are homeless to prevent them from developing greater problems. This work is under way as one of our service improvement initiatives.

I will ask my colleague, Mr. Ryan, to comment on the forensic services. We currently have in-reach in all of our prisons. This has been a significant development over recent years. The Central Mental Hospital Dundrum will soon move to Portrane. We have staff going into every prison and we have different initiatives in certain prisons. In regard to infrastructure, there is always a difficulty in this regard. A significant amount of HSE funding is being spent on the new children's hospital, which is the second largest capital development. The forensic hospital is the largest mental health capital development ever. We know that we have other facilities that are not meeting their requirements. We are regulated and environment is a key concern for the Mental Health Commission. Some of our units that were developed in the 1990s are struggling to meet compliance. We have a constant improvement programme. Deputy Buckley mentioned the need for money to remain in mental health services. If he were to ask people working in mental health services about the spend on infrastructure, they would say that one of biggest differences for service users was the improvement in their environments. We have a long way to go on this and if we really want to improve our service model, we need to develop better day hospitals and nicer units. We are lucky in that we have a footprint in many of the new primary care centres as they develop but there are still lots of gaps around the country. I will hand over now to Mr. Ryan.