Professor Brendan Kelly:

I thank the committee for this opportunity. My evidence reflects my views as an academic clinician and not necessarily the views of my employers. I am professor of psychiatry at Trinity College Dublin and consultant psychiatrist in the public mental health service. My chief interest is social justice and safeguarding mental health, freedom, autonomy, and social well-being as reflected in Articles 16 and 19 of the UN Convention on the Rights of Persons with Disabilities. I submit that Ireland is failing to safeguard these rights for people with severe mental illness such as schizophrenia and bipolar disorder. These failings, although not deliberate, are widespread, systematic, predictable and preventable. They constitute a form of structural violence that amplifies disability, stigma and social exclusion. I will outline three challenges and solutions. These are treating mental illness, safeguarding liberty and safeguarding social and medical well-being in the community.

Mental illness is treatable, mostly by primary care and community teams. Ireland devotes 5.1% of the health budget to mental health. Sláintecare recommends 10%. The World Health Organization suggests 12% and in the UK, it is almost 13%. Ireland has the third lowest number of psychiatry inpatient beds per 100,000 population in the EU. Recruitment problems are endemic. Consultant posts commonly attract zero applicants. These deficits severely impact rights, especially full inclusion and participation. That is the first challenge, namely, treating mental illness. What are the solutions? Mental health services require 10% of the health budget. The division between mental health and addiction services needs to be resolved. Addressing service deficits will help recruitment.

With regard to safeguarding liberty, in the 1950s Ireland had more than 20,000 people in psychiatric hospitals, the highest rate in the world. By 2020, we had 1,826 adult psychiatry inpatients and 50 inpatients aged under 18. This is a dramatic reduction. Our involuntary admission rate is half that of England. This is very positive but low admissions come at a price, which is people with mental illness in prison, homeless or at home and too ill to accept treatment but not ill enough for treatment without consent. My colleague Professor Gautam Gulati led reviews of mental illness in Irish prisoners and found elevated rates of mental illness, substance misuse, homelessness and intellectual disability. Prison is toxic for people with mental illness. That is second challenge, namely, disproportionate deprivation of liberty. What are the solutions? Proposals before the Oireachtas to update the Mental Health Act 2001 should be revised and progressed. The Assisted Decision-Making (Capacity) Act 2015 is due to commence in full. The HSE national office for human rights and equality policy is doing superb work to ensure it helps safeguard autonomy. In 2021, the Inspector of Mental Health Services noted we have an excellent but under-resourced and overworked court diversion service. He added that we "still have people who are severely mentally ill locked in isolation units and other areas of prisons awaiting mental health care in appropriate settings". We need prison in-reach and court liaison services in all areas.

With regard to safeguarding social and medical well-being, Article 19 of the UNCRPD articulates the equal right of all persons with disabilities to live in the community. A study at one psychiatry unit found that 38% of all inpatients and 98% of delayed discharge patients had unmet accommodation needs. Data from other countries confirm that men and women with schizophrenia die 15 years and 12 years earlier, respectively, than the general population. The chief causes are cardiovascular disease and cancer, both amenable to risk reduction, screening and early treatment. Antipsychotic medication is associated with reduced risk of early death in schizophrenia. In 2019 the Inspector of Mental Health Services pointed out that "Patients with serious mental illness experience reduced access to health care". US data confirm that people with a recent diagnosis of depression or schizophrenia are seven times more likely to get Covid than people without mental illness, are more likely to require hospital admission and are more likely die of the infection. This is the third challenge, namely, safeguarding social and medical well-being in the community. What are the solutions? They include systematic co-working between mental health services, primary care, and social care. Individual health identifier numbers would help connect services. Psychiatric treatments work well but they are no substitute for a roof over your head and a community that values you. Safeguarding matters, including the work of Safeguarding Ireland. We need legislation that balances protection with autonomy.

I am very happy to address legislators today. Rudolf Virchow, the 19th century German pathologist and politician, said "medicine is a social science, and politics is nothing but medicine on a large scale". Closer to home, in 1977 Charles Haughey concluded that healthcare is about good government and cannot, in the words of the cliché, be taken out of politics. I thank committee members for their attention.