Mr. John Saunders:

I thank the Chair. I will give a brief response, given the time limits. On unregulated mental health care services, only approved residential centres across the country are currently regulated under the Act. We regulate those centres and impose conditions and changes. We can inspect other services but we cannot impose changes upon them. We have the power to inspect and to make suggestions to community residences, community mental health teams in adults' and children's services and every other type of service but we do not have the power under the Act to enforce those suggestions. That is the crucial issue and it is part of the review process to which I alluded much earlier in terms of the services. We know, and it is nothing new to say, that most mental health teams across the country are under-staffed because of supply and other issues.

Deputy Browne raised the issue of duration of stay. In 2011, the year in which the commission began to highlight the issue of children's admissions to adult units, the average duration in those units was approximately 11 days and children then went back to their families or on to appropriate children's services. That has now come down to approximately six to eight days per admission. It is important to understand the background to such admissions. Some children go into adult services because children's services sometimes will not receive people out of hours. Parents sometimes choose for their child, their loved one, to be served locally rather than travel 100 miles or more to a children's unit. There may be a clinical decision that it is the most appropriate location for a child. CAMHS may not be able to support people locally. We earlier mentioned that community mental health children's teams are not sufficiently staffed to provide the support a child might require while living in his or her own home and the last resort is often, therefore, for the child to go to a children's service or, in some cases, unfortunately, an adult service. That may not fully answer Deputy Browne but those are the headline issues.

Deputy Crowe raised a number of issues. There is a problem in regard to transitional services. Between the ages of 16 and 18 a person is constitutionally and legally a child but may be exhibiting adult-type behaviours and there is an issue in terms of who deals with such people. Traditionally in Ireland, the children's mental health service finishes at 18 and the adult mental healthcare service kicks in. There are logistical issues in regard to how teams co-operate with each other or not, depending on the situation. The commission and many others have highlighted inconsistencies across the country in that regard, some of which are partly historical. Some areas of the country historically have better financial resource allocations. If there was a very large institution in an area, a very large budget would have been provided to support it. When the institution closed, that budget may more or less stay in the area.

As mentioned by Dr. Muldoon, local clinical and administrative leadership is often the spark that drives change, such that change is promoted by personality or the dynamic of a team rather than having a national consistent change plan. There are pockets of brilliance and developments across the country.

They are side by side with the more traditional, under-resourced lack of innovation, for want of a better word, in terms of the type of service they provide. We end up with the patchwork to which the Deputy alluded. That is the fact of Irish life in terms of how mental health care services have developed. I hope I have dealt with all of the questions.