Mr. Martin Rogan:

A number of really important points have been made about access. Research into access has been done in the north west. In Donegal, young people were asked where they would go if they found themselves in difficulty and they gave five primary responses, which were: talk to one's parent or parents; talk to a teacher; talk to a friend; get drunk or self-harm. These were all five live available options and, unfortunately, the last two are particularly harmful. One of the great elephants in the room is our relationship with how people self-medicate with alcohol. It is a huge issue for us and is one of the significant oversights in A Vision for Change. In fact, the policy outlined in A Vision for Change sometimes looks more like the mental health policy for Saudi Arabia than it does for Ireland because alcohol is only mentioned twice in the document, which is a problem.

In terms of health promotion in schools, preschools, crèches, etc. and other forms of health promotion such as the one entitled the First 1000 Days, the Mental Health Reform organisation has produced an excellent document that makes a strong bid for perinatal mental health. We know from research done in the US that there are lifelong benefits to be gained when one invests in early childhood interventions such as family supports, quality supports and coping strategies. They are very useful as well.

As Mr. Power has mentioned, e-mental health can help to extend the prevalence challenge and improve the qualify of signposting but we still need to be mindful. In Japan, there is a phenomenon called hikikomori, which refers to about 700,000 young Japanese men who live in their bedrooms and do not interact with humans at all. Their families know these men are still alive because a pizza slice will be missing from the fridge and the men will have retreated back to their bedrooms. Some of the men play computer games against other humans while others will only play against a computer. The men are not recognised as having autism or other mental health issues. They have simply opted out of their communities and we can expect to see some of that issue in the future. We need activities that include sports, culture, and young people being involved in their community space. People who are equipped and skilled to develop young persons in a rounded sense are really important to us. These are things on which we can get a heads up in order to avoid such a phenomenon in the future.

As Dr. Duffy pointed out, staff can work in this arena. It is more agile, responsive and can be more focused but there is a risk that we could strip staff from other front-line services. As an English-speaking country we have some of the finest graduates in mental health professions. I know from Australian and Canadian colleagues that they are thankful to Ireland, as a donor site, for offering up staff. This is an internationally competitive market. Over the past decade the HSE and other health providers were not in a position to outbid better performing economies at that time. The cost of possibly having a home, particularly in the Dublin area, has become prohibitive and it is quite a challenge for mental health services to retain staff in Dublin areas. We need to be creative and imaginative and not imaginary about recruitment. In the UK there is the London weighting model that recognises the additional cost of living in the city. Perhaps such an initiative should be revisited in this context otherwise we simply will not be able to provide services where we have the greatest concentration of the population. That is not a prospect we can entertain.