Dr. Shari McDaid:

I thank the Chair and the members for inviting Mental Health Reform to come before the committee to discuss developments in mental health services. We welcome the attention that is being given by the committee to the area of mental health. By way of background, the prevalence and impact of mental health difficulties is significant and growing. At any time, one in ten adults in this country has a mental health difficulty, while almost 20% of young people aged 19 to 24 and 15% of children aged 11 to 13 have experienced a diagnosable mental health disorder at some point in their young lives. The number of people disabled by a mental health difficulty is also growing at an alarming rate, with a jump of almost 30% in the numbers reporting a level of mental health difficulty that was disabling between the censuses of 2011 and 2016. Importantly, such difficulties can be more debilitating than most chronic physical health conditions. For example, people with mental health disabilities are nine times more likely to be outside the labour force than the general population. This is the highest proportion for any group of individuals with disabilities.

The cost of mental health difficulties is enormous, with figures suggesting it may amount to as much as 4% or more of GDP in some countries. This would equate to approximately €12.4 billion based on Irish figures. To put this in context, a research study on the cost of childhood overweight and obesity estimated the total lifetime cost in the Republic of Ireland to be €4.6 billion per annum. Untreated mental health difficulties contribute significantly in terms of cost. It is imperative that mental health is recognised and afforded appropriate priority within the wider health agenda to reflect its significance in contributing to the burden of disease in Ireland. This will require a substantial increase in mental health funding, including in budget 2020, both to sustain existing levels of service and to develop new mental health services and supports.

I would like to draw the committee's attention three major issues of concern this morning, namely, governance and accountability in mental health services, protracted delays in reform of Ireland’s Mental Health Act 2001 and the implementation of national mental health policy. It is very important to acknowledge the positive developments that have been achieved across the mental health system at local, regional and national levels. Mental Health Reform recognises the dedicated work of Government, its agencies, public representatives, direct service providers, and the community and voluntary sector. These achievements include the development of clinical care programmes in areas such as self-harm, eating disorders and early intervention in psychosis; the introduction of a national framework for recovery in mental health; and the pilot of advocacy services in child and adolescent mental health services. Some positive developments that have been initiated at the primary care level include the introduction of assistant psychologists, the expansion of Jigsaw services and the piloting of e-mental health supports. Mental health has also received significant attention in the Oireachtas through Seanad and Dáil debates and, most significantly, the establishment of the Committee on the Future of Mental Health Care.

While all of this progress is welcome, it has taken place in the context of new challenges. The mental health system suffers from a severe lack of capacity in the face of increased demand, which has pushed the mental health services to breaking point. While efforts have been made in recent years to make up for some of the losses, the old adage of mental health as the Cinderella of the health services is clearly evident in the continued under-resourcing of mental health services and supports. The shortfalls in mental health service delivery are further reflected in the lack of out of hours crisis services for both adults and children. We are disappointed that despite the recruitment of new staff as part of a planned roll out of seven day services across adult community mental health teams, only four additional areas are reporting a seven day service. In April, HSE mental health confirmed that there is no planned date for completion of the cost and implementation plan for providing seven day child and adolescent mental health services. Not only are the child and adolescent mental health services not able to provide 24-7 support around the country; there is not even a date for producing a plan to see how that can happen. A participant of Mental Health Reform’s national My Voice Matters consultation noted that “outside of office hours [there is] no professional to turn to when in crisis- at the weekend for example. [It] makes no sense that people in this day and age still have to go to A&E as [a] first resort. [It] doesn’t help the patients’’ The inspector for mental health services has recently reported “appalling standards” in certain mental health inpatient units and the Mental Health Commission has recently published a report on the lack of physical health care monitoring of individuals in a number of inpatient services across the country. There are myriad other gaps in mental health service provision, including a lack of resources in CAMHS, which has a fundamental impact on access and quality of care. As of September 2018, in the most recent figures we were able to identify, almost 2,500 children were on the waiting list for CAMHS, of whom over 12% were waiting more than 12 months. Lengthy waiting lists also exist in primary care psychology and there are significant challenges for particular client groups to getting access to mental health services, including those experiencing homelessness and those from ethnic minority communities.

We are also deeply concerned with reports from service users of poor quality in mental health services.

Our national My Voice Matters surveys found that over 40% of service users indicated that they had a poor experience of HSE mental health services. Almost 40% indicated that they were not involved as much as they would like in decisions about the medication they take. Two thirds reported that they did not have a written recovery or care plan developed with their community mental health team. Among family, friends, carers and supporters, over 70% were dissatisfied with the extent to which HSE mental health services had considered their support needs. We draw a direct link between the resource issues and the experience of the quality of the services capable of being provided.

In terms of governance and accountability, we acknowledge that between 2013 and 2018, there was an increase of approximately 20% in the mental health budget and of 28% in mental health spend. Despite such progress it is important to acknowledge that it still has not brought us to the same level of funding that was being provided in 2008 before any implementation of A Vision for Change had taken place. Investment in mental health services continues to fall well below international standards. In 2019, just 6% of the total health budget was allocated to mental health, representing an ongoing trend in recent years of significant underinvestment. Sláintecare recommends that mental health spending increase to 10% of the overall health spend.

A report prepared for the Department of Health by the Work Research Centre identified that a comparative positioning of Ireland internationally suggests that the percentage resource allocation to date is lower than in some of the countries with better developed and better performing mental healthcare systems. The data available indicate levels of allocation of between 10% and 30% in countries such as Sweden, the Netherlands, Germany, France and the UK. Recent developments to invest in Ireland's forensic mental health services and the introduction of the service reform fund in the HSE, including the national roll-out of an evidence-based approach to supported employment for people with severe and enduring mental health difficulties, are welcome. However, investment in mental health services and supports must continue and must be increased on a much greater scale to effectively improve the mental health outcomes of Ireland's population. We recommend that public expenditure be increased to 10% of the health budget within ten years to be in line with international standards on mental health funding as a proportion of the overall health budget.

In addition, there continues to be no national mental health information system to report on the full extent of resources, provision, quality and outcomes for community based mental health service delivery. For example, there are no data on the number of people in community mental health services who have an individual care plan, the number of individuals offered a talking therapy, the wait times for such therapies within mental health services and the employment and housing outcomes for people using the mental health services. Mental Health Reform has been calling for such a system in budget submissions since 2013. It is unacceptable that more than 13 years after publication of A Vision for Change there is no information system to account for the almost €1 billion in public expenditure on mental healthcare each year.  We recommend that an interim system for gathering key performance information on the mental health services be put in place as a matter of urgency.

We note that the restructuring of HSE governance and accountability structures in 2018 led to the dissolution of the HSE's mental health division and the abolition of the post of national director of mental health. Despite the appointment of senior management officials responsible for leading on mental health operations and mental health service planning and strategy, it must be considered that the dissolution of these structures within the HSE on mental health may have an adverse effect on driving the reforms necessary to ensure the delivery of a modern, recovery-focused mental health system that adequately protects the human rights of adults and children. We recommend that the post of national director for mental health and the mental health division be restored to ensure coherent leadership in mental health at national level and clear authority and accountability for a distinct, national mental health budget each year.

With regard to mental health legislation, we have consistently advocated for reform of the Mental Health Act 2001 in line with the expert group recommendations on review of the 2001 Act, to ensure that people have their rights adequately protected when they go into hospital for mental healthcare. The Minister has recently announced that the general scheme of the Bill on reform of the 2001 Act will be complete in June 2019 and ready for the Mental Health Commission's consideration. Given the lengthy delay so far and noting that the expert group's report was published in March 2015, we are asking for a date for publication of the full reforming legislation before the end of 2019. It is also of fundamental importance that the Mental Health (Amendment) Act 2018, signed into law by the President in May 2018, is commenced as a matter of priority to ensure that those small but significant changes can be made immediately to the 2001 Act. This includes that people are encouraged and supported to make their own decisions about their mental healthcare.

Implementation of the national mental health policy is a concern. Significantly, the oversight group tasked with reviewing Ireland's current national mental health policy is due to complete its work and the publication of its report is imminent. In accordance with the terms of reference of the group it can be expected that there will be a much greater focus on early intervention and prevention, mental health in primary care, improved access to mental health services, the development of services to appropriately meet the needs of particular groups of people, such as individuals experiencing homelessness, people from ethnic minority groups and those engaged with the criminal justice system, and the social inclusion of people with mental health difficulties. It is an understatement to say that many stakeholders were disappointed with the pace of implementation of A Vision for Change. It is imperative that the revised mental health policy is supported by a costed and timelined implementation plan and the establishment of robust monitoring and review mechanisms.

I will conclude this statement with the comment of one of the participants in the My Voice Matters survey: "It has been seven years since my first contact [with the mental health services] before I have gotten the help I need which I do feel the course of time waiting made a lot of things worse in my life". I thank the committee for its time and I look forward to members' questions and comments.