Ms Anne O'Connor:

I will answer some of the Senator's questions before handing over to Mr. Ryan. We are in violent disagreement about the whole primary care issue. We all want primary care to be better resourced to deal with mental health and we are doing a great deal of work with the Irish College of General Practitioners, ICGP. We have a project which is examining specifically the physical health of people with mental illness because we know that the physical health of people with severe and enduring mental illness is very poor and their life expectancy is much lower than average. We have a significant amount of work under way with the Irish College of General Practitioners looking at improving physical health and ensuring general practitioners are trained and work with us in this area.

I referred to the whole of society and integrated approach to mental health. As I may have mentioned last week, we are firmly of the view that we need our specialist services to be very specialised and very good but we are at a stage where, with A Vision for Change having set a particular model for us, which is great, we need to do a substantial amount of work in primary care. We know people do not have sufficient access, general practitioners do not have sufficient supports available for people and so forth. We are committed to addressing all aspects of this and working with the ICGP. General practitioners are also represented on the Connecting for Life cross-sectoral group. We are at one in our view on that issue.

In terms of well-being, Healthy Ireland is guiding much of what we do. Using Healthy Ireland, Connecting for Life and A Vision for Change, we are trying to drive a number of initiatives to promote positive mental health. Historically, the mental health division has not focused on mental health promotion. However, we have done a significant amount of work in this area in recent years through the National Office for Suicide Prevention. This includes running the Little Things campaign. We are also working with colleagues in health and well-being in primary care to look at a variety of models around messaging, mental health promotion and general population approaches to mental health.

The Department of Health engages regularly with An Bord Altranais and the HSE engages with the Department. The Department recently negotiated a change in respect of advanced nurse practitioners under which it is no longer the site that is improved. There are a number of obstacles and the Department is engaging extensively with An Bord Altranais. We do not engage with it directly because we go through the Department.

In terms of contracts, we try to be as flexible as we can. We send out all sorts of messages around staff coming to work for us. If the issue is one of working part-time, we try to hold on to staff and try to recruit them on any basis in terms of the hours they will be available for work. We work within the broader public sector, however, which means certain limitations apply to contracts and it is not necessarily within our gift to offer anything. Nevertheless, we try to be as flexible as we can.

In terms of accident and emergency models, we are examining this issue very intensely. There are two groups of people in the mental health services. The first is those who are known to the services and may have been in our units. They will have attended teams, experienced a crisis and often return to an emergency department. We are not happy that this is occurring and we believe other models are available. We are examining models used in the United Kingdom, for example, and in 2018, we intend to develop one site where people will be seen in a different way.

Part of the challenge we face is that A Vision for Change specifies that people should present to emergency departments. We have to manage the policy and the feedback we receive from everybody. Our priority is the group of people who are known to mental health services. The challenge we face is how to provide a service where people can be properly assessed. The statistics show that people who have a history of mental health problems are not always fully screened in respect of their physical health when they attend an emergency department. There is always a risk that we treat people differently because they have a mental health problem and we miss a physical health issue. We have to be careful about that. There will be lots of protocols to work out in terms of how a facility should work.

The second group of people are those who are not known to the services. These individuals will have to visit emergency departments until we find a different approach. Hopefully the review of A Vision for Change will help in that respect but current policy dictates that we take a particular approach. I ask Mr. Ryan to address the issue of prisons.