Dr. Ray Walley:

There can be terminology used in training whereby one has a heart sink patient. However, we are saying the service is heart sink. Over the past three, four or five years there has been an improvement in the pathway methods in regard to child and adolescent mental health. I agree with the Chairman that we are on a learning curve as well because much of the service is not there. For example, only in recent years have we had things like a more defined early intervention team service with, it is hoped, support from speech therapy, occupational therapy and all the other therapies. In some cases we would have sent people into CAMHS, but we were generally given feedback to direct them in a different way.

We recently had an email debate about CAMHS among our GP committee which highlighted that it is very difficult for even the moderate and severe patients whom we are referring in to get seen. I know of two cases in north Dublin in the past seven days. Obviously, I have to be careful about the details. One of them was very young - under ten years - and one of them was young. Basically, the GP in question discussed the case with the child and adolescent mental health consultant in the daytime and the advice was to send that case to Temple Street hospital, meaning that we could not get an appointment for a very severe case because they were under so much pressure. The same happened with the older child. These cases were identified as needing to see a psychiatric service.

I agree with the Chairman that at the start of this referral system, since we were learning what to send and what not to send, there probably was an over-referral. However, I cannot say it is there now. Automatically, we have somebody coming in. These are children. Automatically, we feel for the family and for the patient. We know automatically that the patient is on a long waiting list on a referral pattern. Basically, such a patient will get a knock back. If I make a referral, I know there will be at least one knock-back letter.

Then one is trying to engage with someone to say this is where we are going and some might come in but that is not a service. They are very stretched with what they have. Some of our referrals come from school principals who are already dealing with these issues and are involving the allied services within education and they are stretched too. Four or five years ago I would have agreed that there was over-referral because we were learning the system but not now. It has not been an agenda item on the contract.