Mr. Mervyn Taylor:

Sage Advocacy welcomes this opportunity to make a submission to the Joint Sub-Committee on Mental Health. We thank members for this opportunity. I am joined by my colleague, Ms Róisín Clarke, who was a founding member, with me, of Sage Advocacy and was, until recently, interim CEO of Mental Health Reform. Sage Advocacy is the national advocacy service for older people. We also support vulnerable adults and healthcare patients in certain situations where no other service is able to assist. We provided information, support and advocacy to almost 5,000 people in 2022 and our work on behalf of clients is independent of family, service provider and systems interests. We ensure that people's voices are heard, their wishes are taken into account and they are assisted, in whatever ways necessary, to be involved in decisions that affect them. Our motto is simple: "Nothing about you without you".

In the course of our work, we engage with clients and family members who have mental ill health and sometimes considerable mental illness, but we do not believe, as we are currently structured, skilled and funded, that we are capable of being the sort of dedicated advocacy service that people with mental health difficulties require or deserve. Owing to the nature of our work, we see mental health in older age as less about the provision of clinical services, important though they are, and more about the causes of stress for older people as they face into the challenges of later life. I will cite some examples of these challenges. One is family members taking possession of their home when they are in hospital. It is not uncommon for Sage Advocacy to have to assist people to regain possession of their own home arising from the actions of avaricious relatives. It is hard to believe but it happens far too frequently.

Older people are shoehorned into nursing homes for a period of convalescence following an illness and then funding is organised through the nursing home support scheme without the clear consent of the older person. In other words, older people are sent to limbo and may be deprived of their liberty in a place of care. Another challenge is deprivation of liberty in places of care arising from the views of health and social care professionals, a shortage of home supports and a bias towards care in congregated settings such as nursing homes. The use of convenience medication, which is a nice term for chemical restraint, and incontinence wear to ease work pressures associated with shortage of staff and unwillingness to support older people with continence issues in the community, and insisting that the care can only be provided in a congregated care setting, that is, a nursing home, is a challenge. Health services in the community are already inadequate, including mental health services, and are not available to people in older age, especially in congregated care settings, and there is poor clinical governance in congregated care settings despite strong recommendations by Sage Advocacy and the expert group on nursing homes which reported in 2020. There has not been sufficient progress following the report of the expert group on nursing homes and the recommendations about clinical governance in nursing homes.

A considerable source of stress arises from widespread confusion regarding the status of next of kin. This creates an incredible number of rows within families and with service providers. Next of kin simply means someone who people would like to be contacted in an emergency. Being a next of kin provides no legal standing whatsoever despite widespread belief to the contrary. A RED C public opinion survey in 2018 found that 57% of people believed that next of kin was someone who can make healthcare decisions about them if they are unable to do so. That is a frightening figure. Equally worrying was that 32% of people believed that next of kin was someone who can access their bank accounts and assets they are unable to access.

The issue of next of kin is closely tied in with another key issue facing older people, namely, safeguarding. Sage Advocacy looks forward to the long-awaited report of the Law Reform Commission on a legislative framework for adult safeguarding.

We strongly urge this committee to support the establishment of a national adult safeguarding authority, preferably under the aegis of the Department of Justice. This would reinforce the point that adult safeguarding is a rights protecting and enhancing practice which needs an interdisciplinary approach involving social work, healthcare, policing, financial and research skills. The Adult Safeguarding Bill was brought forward in 2017 and despite having all-party support, it has not progressed through the Oireachtas. I understand that the Cathaoirleach has a particular personal interest in the issue and we appreciate that.

When the report of the Law Reform Commission is published, this Adult Safeguarding Bill should be progressed with all necessary speed. In the meantime, a simple change to existing coercive control legislation to allow it to relate to people in non-intimate relationships would be helpful. In 2015, the expert group review of the Mental Health Act 2001 recommended a range of advocacy supports including both peer and representative advocacy as a right for all individuals involved with the mental health services. The commencement of the Assisted Decision-Making (Capacity) Acts, effectively next week, and the operationalising of the Decision Support Service under that legislation, planned legislation to protect the liberties of people in places of care and the long-awaited report on a legislative framework for adults safeguarding from the Law Reform Commission will all contribute to a growth in demand for independency advocacy services.

Sage Advocacy asks the Sub-Committee on Mental Health to address this emerging need for independent advocacy and the related need for appropriate structures, funding, training and co-ordination through the establishment of a national advocacy council.

The life cycle approach to the challenges of older age is an important one, which is informed by older people’s actual experiences as they move further along the life cycle. A lessening of physical abilities and decision-making capacity associated with older age requires not just the provision of the more easily understood supports and services such as home help, transport, social clubs, day centres, meals-on-wheels, respite care and congregated care but also investment in supports and services which can assist older people as they experience cognitive decline, avaricious relatives, coercive control, emotional and financial abuse, legal problems and the provision of services in a manner that suits service providers and reproduces institutional approaches.

The interplay between mental health, chronic illness and older age requires that we ask questions about how effective the life cycle approach is and how well it is being implemented. For many older people the support and service options available to them decrease as they grow older. There is still a clear bias towards care in congregated settings; places in which weak clinical governance and the dangerous architecture of the nursing home support scheme combine to restrict access to necessary services. It is really important to understand that at the end of the life cycle, people in a nursing home are there for an average of two years. It is the last period of their lives and the services, limited though they might be in the community, are very often extremely hard to get because they are seen as being cared for in this congregated setting. In planning for the new regional health authorities which are going to emerge in the next few months and will officially be up and running from January 1 next year, it is vitally important that mental health supports and services are planned for across the continuum of publicly funded services, including where they are privately run.