Dr. John Hillery:

I thank members for being here. Yesterday was a busy and long day for them all.

It is very good that the committee is addressing this report. From our point of view and that of many members of the public, it is one of the most important reports to come out in the past few years as regards mental health. It is especially important, as will be seen from the report, that the majority of health problems suffered by people under a certain age are mental health problems. That brings us back to another issue I have addressed previously but which we will probably not address today, namely, the need for parity of esteem between physical and mental health as regards services and resourcing.

The report, Independent Review of the Provision of Child and Adolescent Mental Health Services (CAMHS) in the State by the Inspector of Mental Health Services, is now known as the CAMHS report so I will address it as such. When I have completed our opening statement, I will turn to Professor Lucey who will be very helpful to the committee regarding the importance of regulation, standard setting and inspection in provision of health services in general, and specifically as regards why we are here today.

As the Chairman kindly said, I am accompanied by Mr. Farrelly, chief executive of the commission, and Professor Lucey, who is just a month in the job as Inspector of Mental Health Services. That brings me to the fact that Dr. Finnerty, who worked long and hard on producing this report, retired a month ago and so is not present. To avoid confusion, when I talk about the inspector, I will be talking about Professor Lucey and when I talk about the report and the previous inspector, I will say Dr. Finnerty, if that is okay.

The main point the commission wants to make is that the implementation of this report cannot wait. As members know, there are 49 recommendations, most of which do not apply to the Mental Health Commission but to outside bodies. There needs to be independent monitoring of their implementation. That implementation needs to be rapid and independent monitoring should be established immediately. Dr. Finnerty has said, and we agree with her, that the Mental Health Commission has the skills and resources to do this. The commission should be asked to do this and be given the powers to do so. We also say, along with Dr. Finnerty, that the regulation of CAMHS needs to be put in place immediately. In the new mental health Bill, which it is to be hoped is coming in the next Dáil session, there will be moves for that to happen but we do not think it can wait. Under the current legislation, it can happen now. We have asked the Minister of State, Deputy Butler, and the Minister, Deputy Stephen Donnelly, to expedite this to allow the Mental Health Commission do this straightaway so we can set standards and inspect them.

I will talk briefly about the role of the commission. It now has two main responsibilities. The long-term one has been the regulation of inpatient mental health services throughout the State. More recently, we are also responsible for the Decision Support Service, which is not why we are here today but I know members will all be well aware of that. We are the regulator for mental health services in Ireland and an independent statutory body established under the Mental Health Act 2001. Our mandate under the Act is to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to protect the interests of persons admitted and detained under the 2001 Act.

The next matter seems to have come as a shock to people recently when the inspector referenced it on the radio but it is a fact. We can currently only inspect and regulate approximately 1% of mental health services in the State because we are limited to adult and children inpatient services. As members will all be aware, most treatment of mental health problems is now community-based, which goes from support services through to general practice and mental health services in the community. However, we have no remit at present under the Act to inspect them. That means that every other mental health service in the State other than residential inpatient ones, including community CAMHS, is not regulated. Most of the professionals who work in those services are regulated under the various regulatory bodies that apply but the systems and premises, and the providers responsible for those systems and premises, are not. As I said, this seems to have come as a shock to people when Professor Lucey said it on radio recently but it is an important fact.

The Inspector of Mental Health Services has the statutory power to visit, inspect and report on any premises where a mental health service is being provided. However, neither the inspector or the commission has the powers to set standards and ensure services comply with these by way of monitoring and enforcement, except the 1% I referenced. In her report, Dr. Finnerty recommends that the commission should be given statutory powers to immediately work with stakeholders and clinical staff to develop standards and rules for the provision of CAMHS community services in Ireland. As I said, I will ask Professor Lucey to address that issue. The general scheme to amend the 2001 Act, approved in July 2021, set out the intention of the State to expand the regulation of mental health services beyond inpatient services and into the community. That should imply that child and adolescent psychiatric and mental health services would also be regulated, but they are not at the moment.

I will probably be stating the obvious regarding the report but I will state it anyway. CAMHS provide assessment and treatment for young people up to 18 years of age who experience moderate or severe mental illness. CAMHS treat depression, problems with food and eating, self-harm, attention deficit hyperactivity disorder, psychosis, bipolar disorder, schizophrenia and anxiety, among other difficulties. CAMHS, therefore, is focused on the more serious end of mental healthcare for young people. Members will see that one of the issues raised in Dr. Finnerty's report is there does not seem to be any triage system for parents, teachers or community workers, if they are worried about a child or adolescent, as to where they should look for help. Many people end up going to their general practitioner, who is in an unequal position and ends up referring them to CAMHS where they may be on a waiting list for those services, even though that may not be what they need. That is one of the issues Dr. Finnerty addressed in the report and one that needs change.

Sadly and alarmingly, members will recall that when we launched this report, Dr. Finnerty said she could not provide an assurance to all parents in all parts of Ireland that their children would have access to safe, effective and evidence-based mental health services. Some of the findings in the review included gaps in governance, both at corporate and clinical level; poor risk identification and management, with serious risks unidentified and poor or no response when they were identified; and a wide variation in scope and capacity of CAMHS teams, resulting in “a postcode lottery” for parents and young people. There are many reasons for this. Some are about staffing levels and some about philosophies in each team. One of the messages that needs to come out of this report is the lack of uniformity throughout the country as to how these services are driven, which is one of the key things that needs to change. That leads to the next finding, namely, a lack of clinical leadership at community healthcare organisation, CHO, and national level resulting in some unsafe practices, inconsistent care and failure to adhere to standards and guidelines. Even though standards are not set by the Mental Health Commission, there are internationally agreed standards on approaches to certain problems that present in childhood and adolescence. It was, and is, worrying that the inspector found this was not always the case in various places throughout the country. It is important to say that this is not just between CHOs. Dr. Finnerty found issues within CHOs too, with differences in how these were approached.

Members may remember that Dr Finnerty recommended that a comprehensive strategy for CAMHS and all other mental health services for children be prepared and approved by the HSE board as a matter of urgency. Despite targeted improvements by the HSE to solve some of the issues, Dr Finnerty stated that it is a major concern that there are ongoing and serious deficits in CAMHS, which are increasing the risk to children and young people.

Another issue was that of access to CAMHS or to any mental health supports for a child. Members probably know that Dr. Finnerty interviewed many children, adolescents and parents when compiling the report, in addition to community workers who were working with troubled adolescents and children. Access is a key issue and a cause of profound distress and frustration to parents who “expressed concern [at] how their child deteriorated while waiting for an assessment.” Dr. Finnerty went on to say, “Parents did not know where they can get help and information about services for their child and felt that a crisis needed to be reached before appropriate services are offered to them, or that they have to battle with services before help is provided.” At our launch, one of my colleagues on the commission, who is a service provider but also a service user, said this totally echoed her experience as a troubled adolescent.

She was referred to child and adolescent mental health services, CAMHS, but never got an appointment. Finally, when she was 18, she was asked to attend adult services. I believe she said that was two and a half years after she had originally been referred. Dr. Finnerty added that many young people and their families are "frustrated, distressed and are trying to cope with deteriorating mental health difficulties while waiting for lengthy periods on waiting lists for essential services", as I have just illustrated through the example of my colleague. Dr. Finnerty also found that there are certain groups of children who, along with their parents, have difficulties in accessing CAMHS due to language, culture, stigma, fears or location. She went into detail on those various groups in her report. One group I have worked with for most of my career is people with autism. That is a particularly difficult issue in that, in certain areas, CAMHS do not seem to see a role for themselves in dealing with children who have autism even where such children are presenting with difficulties that would result in access to CAMHS if they did not have autism. I do not understand why that happens. It has to change.

It is clear to the board of the commission from the final report, which we endorse, that the current systems for CAMHS are simply not working. As we pointed out at the time of publication and on many occasions before and since, including at the time of publication of the individual community healthcare organisation, CHO, reports on 31 August 2023, these systems lack the basic management, information gathering and oversight structures that are needed to operate safe and effective services. We have sent the clerk links to the various individual reports if members wish to access them. We can also address questions if there are any that we can answer today.

Dr. Finnerty recommended the immediate reform of these structures and also recommended the immediate and independent regulation of CAMHS by the commission to help guarantee that all children have access to evidence-based and safe services regardless of geographical location or ability to pay. The regulation of CAMHS under the Mental Health Act would provide the commission with the statutory powers to immediately work with stakeholders and clinical staff to develop standards and rules for the provision of CAMHS community services in Ireland. The issue of ability to pay is very important because, although there are people in private practice, that does not necessarily guarantee that a child or adolescent who has a problem will be able to get the type of service he or she needs because a multidisciplinary approach is required. Seeing one professional in isolation is better than not seeing anyone but it is not a modern approach to supporting children and adolescents with problems.

Dr. Finnerty found that ineffective governance in some areas is contributing to inefficient and unsafe CAMHS through failure to manage risk, failure to fund and recruit key staff, failure to look at alternative models of providing services when recruitment becomes difficult and failure to provide a standardised service across and within CHOs. Another key issue is the lack of access to information. As a result of the lack of an IT service, paper documents are being used. They often seem to be incomplete and pieces often go missing while information is not shared across the system. If you see one professional and go on to see another, information may not be passed on to the latter. We also found that, although there are difficulties in recruitment, those difficulties do not seem to be as bad in services where there is proper administration, IT and governance.

We also have to emphasise that treating children and adolescents with these problems requires, to use a simple term, a "boots on the ground" approach. You need various professionals from different backgrounds. It is a rotating problem because, if you do not have the professionals in the team, you will not attract other professionals to it and those professionals who are on the team will be put under extra pressure, causing them to leave and go elsewhere. It is a bit like an operating theatre with an operating table. You need an anaesthetist, a surgeon, nurses and a clean environment. In psychiatry, we need certain environments as well. If you want to attract people to work in them, you need to provide those environments.

The lack of a national director for mental health has contributed to these difficulties. I know the committee is aware that this post was discontinued by the HSE some years ago without, as far as I know, any interaction with the Department of Health or the Minister at the time. Most of us who work in mental health services have been campaigning for its reinstatement ever since.

It is the strongly held view of the commission that the HSE, with support from the Department of Health, must immediately start to put together a formal strategy for this restructure of CAMHS and that this must include how all the recommendations from Dr. Finnerty’s review will be addressed and how the implementation of the recommendations will be overseen. However, we also feel that, for the public to be assured, we need independent oversight of the introduction of these recommendations. Once again, and I apologise if I keep repeating myself, we feel that the Mental Health Commission is the obvious body to do this. We feel this does not have to wait for the new mental health Act and that it can be done under the current Act.

In closing, the commission welcomes the committee’s interest in the CAMHS report. It sets out a clear roadmap to help ensure that we can work together to restructure a CAMHS service that will deliver evidence-based and up-to-date supports for vulnerable children and adolescents who need such high-level input for their problems and that, in time, we all can be proud of. The report is practical and straightforward in its recommendations but unless it is actually implemented it will be just another document on a shelf for future review and regret. As I said at the outset, if the committee will give Professor Lucey some time, he will speak about setting standards and regulations. He has been with us for a month. A month ago, he was a consultant psychiatrist on call so he is well aware of the other side of how the Act and regulation work. In a previous role, he was clinical director for three inpatient services, including a CAMHS inpatient service he helped establish, so he is also well aware of what is involved in establishing standards. If I may, I will turn to Professor Lucey.