Dr. Liam Mac Gabhann:

The Deputy highlighted one of the ongoing challenges, which is that people can be pigeon-holed. In Ireland, one of those pigeon-holes is where we put the hierarchy of responsibility. It is on the medical profession. It is burdened with that responsibility. That is a societal issue. Doctors are also in the pigeon-hole of their specialties. There is an important place for a medical approach to dual diagnosis but it is an important place as opposed to all of the space. The special themes for 10% of the population will require quite a lot of that specialist medical intervention. What has happened over the years is that frequently and in fact eternally we have placed the responsibility for dual diagnosis at the doors of the medical profession which is not equipped to deal with dual diagnosis. Its members are equipped to deal with a small aspect of dual diagnosis and the ones that do so, do it well. We know of some of those people. For example, Ms McGillivary works with one of the people who understands dual diagnosis and the psychiatric profession well, but it is a systemic issue. If we work our way backwards, different Departments have always been responsible for alcohol, drugs and mental health. We have different policies for alcohol, drugs, mental health, housing and everything else that relates to the complex issues. That is the systemic challenge that continues. We also train professionals differently. We train professionals in mental health in one way, namely, to understand that taking drugs is bad, which means they are not able to deal with people who are taking drugs and they feel ill-equipped because their culture, training and operational managers tell them not to deal with people who take drugs and-or alcohol. It moves from Department, to policy to operationalisation. Staff in the statutory addiction services - community services are not like this - are ill-equipped, untrained and they believe it is not their job to deal with people who are mentally ill. Those are the challenges we have had over the decades. Going back many decades, to at least the 1990s, we have known how to resolve this. In some jurisdictions, it has been resolved. For example, dual diagnosis co-ordination is needed across the system. Case management, as we mentioned earlier, is the way to resolve the challenge of different cultures, different specialties or different pigeon-holes. Case management is the ability to do this without people falling through the gaps. That solution has been well-known since 1995 and where it is applied, it works.

The cultural shift has been identified as a necessity, but we have not changed the training, requirements or operationalisation of the mandate to enable people to embrace dual diagnosis. For example, mental health services have had a mandate since 2020 to assume responsibility for dual diagnosis, not only for the specialist teams, but to be able to link in with the community in a systematic approach to dual diagnosis. However, nothing has happened to operationalise that policy. We sent people away to come up with a clinical programme. Nothing happened for the first two years. It was dismissed. Then it was brought in again and now we have a clinical programme. Meanwhile the mental health services are not responding. That is because of structural issues. It is not because people do not want to respond. Ms McGillivary, Mr. Williams and I are saying that they have patients with dual diagnosis and want to respond but that they will wait for the hierarchical diktat before they will do so, and they are not getting it at the moment. The solution is to listen to the evidence and not to allow pigeon-holing of the response. Otherwise, only 10% of the population will get a look in. If we respond to the systemic issue of dual diagnosis, which affects, conservatively, approximately 50% of all our caseloads, the solution can be implemented.

The committee heard about at least two examples and, more importantly, heard what the solution is from a person who has tried to access and go through these services. What I mean when I say that the barriers have not been overcome is that we are perpetuating them. However, we have a wonderful opportunity for the first time ever. From a departmental perspective and policy-wise, we have the capacity to respond systemically and as one to dual diagnosis. That has not happened before in the area of dual diagnosis, so this is potentially an exciting time. I can say this because I am on the sub-committees relating to the dual-diagnosis model. Already we see a focus on the specialist 10% of services.

Everybody's gaze is moving towards this, to pigeonhole the medical response to dual diagnosis, but we need to gaze at the 100%. If we can manage the other 90%, there will be less need for the specialist services for the 10%. This 90% will never get a look in. It will only be 10%, maximum, including a residential unit, once we move from the pilot scheme. That is the solution. I do not know if I have answered all of the question properly. I got carried away with the response. I have been involved with this for so long and have been recycling and recycling but I have seen innovations. There are innovations all around the country. They are ready to be capitalised on, but we need the operational drive to make it happen. It is not about waiting two years for the pilot sites to report on how the specialist services have managed to respond to 10% of the population. It is about doing it now.