Oireachtas Joint and Select Committees
Friday, 9 November 2012
Committee on Health and Children: Select Sub-Committee on Health
Health and Social Care Professionals (Amendment) Bill 2012: Committee Stage
Apologies have been received from Deputy Naughten. I remind members to turn off their mobile telephones because, even in silent mode, they can interfere with the quality of the transmission.
This meeting has been convened for Committee Stage of the Health and Social Care Professionals (Amendment) Bill 2012. I welcome the Minister and his officials to the select sub-committee meeting.
I move amendment No. 1:
In page 4, before section 3, to insert the following new section:
3.--Section 4(1) of the Principal Act is amended by inserting the following paragraph after paragraph (l):“(m) psychological therapist.”.”.
Section 9 of the principal Act relates to membership of the health and social care professional council. This amending section is crucial to the continuing function of the council as it will allow the Minister to continue to appoint professional members to vacancies arising on the council until such time as all registration boards that are established under the legislation have held elections or are in a position to nominate elected members for appointment to the council. The phased establishment of the 12 registration boards has meant that in the absence of elected members, professional members cannot be appointed to the council to fill the vacancies arising from the completion of the terms of office of the original 12 professional members. Deputy Fitzpatrick’s amendment attempts to rectify that situation.
The 2005 Act provides for the appointment of 12 professional members out of a total of 25 on the nomination by relevant registration board of one of its elected members. As is usual in such cases and since no registration board would have been established, the Act also empowers the Minister for Health to directly appoint these professional members for the first term. The Act, however, does not allow the Minister to appoint members for a subsequent term pending the establishment of the registration boards. There are currently no professional members on the council. I agreed to allow 12 professionals attend council meetings in an observer capacity. However, they do not have voting rights and are not included when considering a quorum. This amendment would allow me to appoint professional members to the council.
I acknowledge the work done by several counsellors and psychotherapists in coming together under the umbrella of the psychological therapies forum to advise as a single voice in so far as is possible. This is a key component required for the development of common standards of education, training and codes of practice for each individual profession. There is still, however, a considerable amount of work to be undertaken to bring this work to a level that will meet the standards required for designation under the Health and Social Care Professionals Act 2005. In Part 1, the 12 professions designated have long-term agreement and service-wide acceptance of title and recognised associated entry level qualifications required for existing practitioners as set out in Schedule 3. This dual requirement is not established in the case of counselling and psychotherapy. To designate the professional using the title “psychological therapist”, particularly in the absence of a corresponding set of agreed qualifications for inclusion in the grandparent arrangement under Schedule 3, is premature and could have the effect of excluding as many counsellors and psychotherapists as it would include.
However, I am supportive of addressing the regulation of counsellors and psychotherapists sooner rather than later. Replies to parliamentary questions and meetings with various delegations have been based on a policy position that statutory regulation for this profession would be considered for designation by regulation under section 4(2) of the 2005 Act in time to come when all registration boards for the 12 designated professions have been established.
Accepting the concerns raised by Deputies on Second Stage, I now intend to take a different approach with regard to the timeframe for the regulation of counsellors and psychotherapists. I am aware that the Higher Education and Training Awards Council, HETAC, now subsumed into Quality and Qualifications Ireland, QQI, has been working on the development of a standard for the award of higher education qualifications in the fields of counselling and psychotherapy. Parties involved include the higher education institutions, international experts and the Irish professional bodies as represented by the psychological therapies forum. Its work is scheduled to conclude in 2013. While academic qualifications are not sufficient in themselves as a means of professional regulation, agreement on academic standards and quality assurance does form a critical building block for any modern regulatory system for professions such as counsellors and psychotherapists.
I am now committing to have my officials engage with the psychological therapies forum and other relevant stakeholders once HETAC concludes its work and makes a report available with a view to working through the outstanding issues that have yet to be addressed and in a way that achieves regulation of the profession as soon as possible in the best interests of the protection of the public. It should also be noted that section 4(2) empowers me, following consultation with the council, to designate by regulation any health or social care professional not designated under section 4(1) provided the criteria set out in section 4(2) are met by the profession. This amendment is not required to achieve regulation of the profession in question. Also, while counsellors and psychotherapists are not subject to professional statutory regulation, they are subject to legislation similar to other practitioners including consumer legislation, competition, contract and criminal law.
Accordingly, I cannot accept this amendment. As a general practitioner for over 25 years, I have always been concerned about referring my patients to a credible individual who had basic standards of professional qualification that ensured my patient got the service he or she required.
I welcome the fact the Minister has put on the record a commitment to afford due regulation and recognition of counsellors and psychotherapists within a reasonable time. I hope it will be realised within a reasonable period. He has stated it is in the interest of the patient, the public and the profession. Only a month has elapsed since we last addressed this legislation.
Has there been any progress that the Minister can share with us in relation to the 12 boards that must be established across the 12 professions listed in the legislation? I recall that on Second Stage of this legislation we were talking very low numbers indeed in terms of progress towards the establishment of the registration boards. The reason the legislation had to be introduced in the first place was so the Minister would be in a position to appoint professional members to the council until such time as they were established. I ask for an update in that regard.
I use the area of speech and language therapy as an example but this would apply across each of the areas covered in this legislation. There is a significant number of highly qualified speech and language therapists, many of whom are being forced to leave our shores. They are available to take work and the demand is most certainly there, as all voices in this committee have highlighted time and again, as did the Minister, Deputy Reilly, in his previous role. Is there any light at the end of the tunnel on lifting the embargo on recruitment in order to provide jobs at home for highly qualified young speech and language therapists and to meet the identified demand right across the State? It is an appropriate opportunity to raise the matter and to ask whether the Minister can give us any hope that this matter will be addressed in the short term.
I want to give the background to why amendment No. 1 was not included in the first place. This was debated at length during the debate on the 2004 Bill where an amendment was proposed by former Deputy McManus and seconded by me. The then Minister of State, Mr. Tim O'Malley, was supportive of it and would have included it only that the various organisations were in disagreement about whether it should be included. At the time, Mr. O'Malley stated, and the Government assured us, that once the organisations agreed to do so, he would then add it immediately under the Act. The organisations came together and in 2008 published their proposals and acceptance to include it in the Act. We were assured in 2005 that once the organisations agreed, the Government would add it. When we went to have that done, and I put down questions to the then Minister for Health and Children, Ms Harney, she stated the Government would do so but the 12 boards would have to be completed first. It has been repeated that the 12 already designated would take priority even though the reason psychotherapists and counsellors are not included is not because they should not have priority, but because agreement could not be reached at the time and the legal advice to the then Minister was that agreement should be obtained before the registration. At the time the psychological therapies forum published and presented to the then Minister and we were assured that it would be added, but, repeatedly, including this morning, we have been told that this cannot be done until all 12 designated professions are done.
There is extreme concern about untrained psychotherapists and counsellors who are giving dangerous advice. I am aware of this from, for example, Bodywhys, the excellent eating disorders support group, in the case of one of the courses. Eating disorders are a highly complex area, involving psychological, emotional, psychiatric and physical difficulties. It is the highest cause of death among young people outside suicide.
Mr. John Mooney of The Sunday Times did serious research into this and published an article on 6 November last year. He wrote that a high profile psychotherapist who offers diplomas in the treatment of eating disorders has no professional accreditation in Ireland and has not obtained any medical or psychological qualifications from any university. The Eating Disorder Resource Centre of Ireland is run by a certain person. I would prefer not to mention the name, but it is in the public domain. A former anorexic who lives in south Dublin offers diploma courses for up to €3,000. The diplomas, which take eight weekends to complete, are accredited by the British Psychological Society, the chief executive informed Mr. Mooney. A spokesman for the society stated it does not recognise any courses offered by the organisation. The organisation advertises counsellors and psychotherapists who are linked to the organisation, which is run from her home. More than 100 persons have taken the course in the past five years, which means there was income of up to €300,000 from that weekend course alone. The potential client interested in working with vulnerable people would believe that the course is well accredited, but it is not accredited. The course operator stated she had five persons booked already and one would get a diploma in practitioner's skills for eating disorders that is accredited. The Sunday Times sent in applicants to see if they would get on the course without any qualifications or interest in the area, and there was no problem in them getting on the course. In fact, my secretary did it some years ago and she was given a handwritten note to start the following Saturday. Another course for a higher diploma in the area of suicide is done over six weekends. It is highly dangerous stuff. These people set themselves up to advise and the facilities under the 2005 Act would deal with that. It deals with all of that area of supervising psychotherapy and counselling.
The Minister was involved in a debate on a controversy yesterday and although I will not go into it, that could be dealt with under the complaints procedure of the Act. If this was set up under the 2005 Act, as we requested, the issue raised yesterday could be referred to the board to deal with any complaints.
I do not understand why the position on advice to the Minister in 2005 does not still stand. Why has everything changed so much in the meantime? We were promised it in 2005. That was eight years ago and nothing has happened. The psychological therapies forum reported five years ago and nothing has happened. No registration board has been established for any of the 12 in eight years and now we are told that when all of these are done, the Minister will deal with the counsellors and therapists to whom I refer. Will it take ten, 20 or 30 years to do it and what damage will be done? How many will die from suicide? How many will have serious health problems or social problems because of wrong advice?
The organisations involved in these areas are conscious of the need and complaints have come in, including one complaint to Bodywhys where a counsellor in eating disorders discussed another patient's condition, and named the patient, in comparing situations.
That is what we want to address. These bodies would have been included in the 2005 Act but for legal advice regarding the disagreement between the associations.
Deputy Caoimhghín Ó Caoláin asked, very reasonably, for an update. Two councils have been set up, namely, the social workers board and the radiographers board. I have just signed the regulations for speech and language therapists, occupational therapists and dieticians. There are now five councils. We are well advanced in the case of physiotherapy and hope to have the registration board established in January.
Deputy Dan Neville raised a serious issue. I share his concern about the lack of standards and the fact that people who have taken courses over six weekends are calling themselves counsellors in the same way as those who have completed three or four year university courses or postgraduate degrees in psychology. We have to address this issue, but I hope the committee will give me its forbearance because, as Deputy Dan Neville correctly pointed out, there was no agreement among the various counselling bodies on the issue. While they have now come together, they have as a consequence of speaking with one voice highlighted huge gaps in standards and we will have to do considerable work with HETAC to develop a shared standard. HETAC intends to provide us with a report on the matter in early or mid-2013 which will allow us to start immediately with the task of setting up a registration board for counsellors.
I do not underestimate or dispute anything Deputy Dan Neville has said. This is a serious issue at a time when mental health problems causing distress are rampant in this country. In the past fortnight I attended two funerals of two people, a pharmacist and a GP, who had taken their own lives. I am aware of others and also had the sad experience of attending the funerals of a friend who had taken his own life four years ago and his son who had done the same only a few months ago. This is an issue that requires significant attention and resources, but we have to ensure the resources provided give us the outcomes we need. Therefore, it is important that people who are either referred or present themselves to counsellors are dealt with by individuals who are suitably qualified. It is a well known fact that people who are not properly qualified can do terrible damage.
I hope the committee will understand that while I cannot accept the amendment, I am undertaking to progress the issue as quickly as possible. HETAC is working diligently on the issue and when we reach agreement on standards, we can proceed on the basis of a statutory instrument, with the establishment of a registration board. I hope to have this done not in another ten years but in the next 18 months to two years.
I do not doubt the Minister's bona fides, but Ministers have been giving me similar assurances for eight years. Implementation of the 2005 Act was to be self-financing through charges for registration and certification. We are not asking the Minister to set up a registration board before his work has been completed, but the Bill offers him the ability to make a decision on it. Nothing was done about the 12 bodies already designated until 18 months ago. I am not saying he should set up the registration board immediately, but I want to give counsellors and psychotherapists the same status as dieticians, social workers and physiotherapists under the Bill. We will be told again that the 12 designated professions will be dealt with first. The work is not being done in a chronological order because the second last profession on the list is being considered. If psychotherapy and counselling are added, we will not expect the Minister to establish the registration board before he is ready to do so. We want to give psychotherapy and counselling the same status as the other 12 professions in order that in future we will not be told, in an answer dictated by the Department, that they cannot be included until the others are designated. We do not want the matter to languish for another eight years.
I clearly recall the presentation of the initial consideration dating back to the period to which Deputy Dan Neville referred during the tenure of the last Administration and the then Minister for Health and Children, Mary Harney. It was something I supported at the time and the Deputy has made a sustainable and convincing case. The point he makes on including psychological therapists and counsellors at this juncture merits the Minister's serious consideration. I will certainly support the amendment if it is pressed. Given that we have received confirmation that only five of the 12 designated professions are in a position to proceed with their own registration bodies, perhaps the Minister might reconsider the arguments presented by the Deputy.
I thank the Minister for providing information on the progress made on registration bodies, but he did not respond to the important question I raised regarding speech and language therapy and the prospect of lifting the recruitment embargo in recognition of the number of highly trained speech and language therapists who are in danger of being forced from our shores. I spoke about the identified demand. I wish to amend my use of the phrase "identified demand" with "identified need" to place even greater emphasis on my appeal. Will the Minister give us some hope this intolerable situation may be coming to an end?
I completely accept Deputy Dan Neville's bona fides and share his concerns. However, I have to face the reality that under Schedule 3 to the Act, the qualifications for each of the named groups are defined. There is no such definition of psychological therapist. Even the term "psychological therapist" cuts across psychiatry and psychology. There are legal implications for psychiatrists and psychologists. Please do not misunderstand me; I want to expedite this issue, but I cannot do so technically because the qualifications are not defined under Schedule 3 and we need to allow HETAC to complete its work before we can progress the matter.
Section 4(2) of the Health and Social Care Professionals Act 2005 states:
After consulting the Council, the Minister may, by regulation, designate for the purposes of this Act any health or social care profession not already designated under subsection (1), but only if--
(a) the fitness of the members to practise their profession is not regulated by or under another Act of the Oireachtas,This is a clear licence for me and I am giving an undertaking here to do it. I must take the advice of the experts. It would be very easy for me politically to accept an amendment, but I could then find myself in a legal nightmare, and I do not want to do that. We are all trying to protect patients and consumers from people with substandard qualifications who present themselves as something else. I want to do this as quickly as possible, but it must be done according to the law under advice from legal people. I accept totally what the Deputy said about the Fine Gael motion when it was in opposition, but again, if there are legal implications, we cannot just close our eyes to them. We must take the advice available to us.
(b) the Minister has given interested persons, organisations and other bodies an opportunity to make representations to him or her concerning the proposed designation,
(c) the Minister considers that it is appropriate and in the public interest that the profession be designated under this Act, and
(d) the steps in subsection (8) have been taken.
I want this to be done and dusted by 2014. It will be if I have anything to do with it, and I will have a lot to do with it. It is an area about which I am particularly concerned because, as a practising doctor for years, I was always terribly concerned about the standard of people to whom I referred patients. If I referred someone to a consultant I knew the consultant had a particular standard of training, and the same is true of a physiotherapist. However, I did not know what I was dealing with if I referred someone to a counsellor. The only parameter I could use to give some protection to the patient was that the person was HSE-approved. I agree 100% with the Deputy on all of these issues. However, there is a technical legal issue which I cannot overcome. Therefore, I cannot accept the amendment.
Given the escalation of mental health issues in society, there is growing concern about an increase in the number of less-than-qualified people offering advice under the guise of being qualified counsellors and psychotherapists. As somebody who has engaged with these and who was there myself, I know it is a sensitive and important area. We saw what happened in recent weeks. The committee members are unanimous in saying that we do not want to be in a legal situation that causes untold trouble down the line. We need to see an end to the situation in which people can open their weekly newspaper or parish newsletter to see an advertisement saying person X is available to do A, B or C when that person's qualification is not worth the paper it is written on. This is what we are all afraid of. People go to such practitioners and come out worse than when they went in. We must stop this. I respect and understand where the Minister is coming from.
I concur completely with the Chairman's comments and his sentiment. I know this is the view of the committee. I ask members to bear with me. I would be happy to come back to the committee to give regular updates on how we are progressing with this.
We will not have the qualifications defined by then. HETAC has an important role, and that is the difficulty we have. In a rush to do things which have been hanging around for years-----
I understand the anxiety about this and the need to expedite progress, and I will do so to the best of my ability. I will encourage HETAC, through my colleague at the Department of Education and Skills, to get on with it in a much more aggressive fashion than perhaps has been the case heretofore. I cannot walk the Government, the committee and myself into a legal mess to the detriment of patients and have everything set back.
My silence so far might indicate that I was not supportive of Deputy Neville's proposal, but we must bow to his experience and knowledge in this field. He has spoken about it passionately and with purpose for many years. Has HETAC been asked to carry out a mandate in this matter? I have had dealings with HETAC over the years. Has it been given a clear and concise opinion that this must be revolved within a specific timeframe? Are we wondering when it will report back and when it will come to conclusions on courses and qualifications? I am concerned because I have been around here long enough to know years can become decades very quickly. In the meantime we have an escalating crisis with regard to self-harm, suicide and other mental illnesses, which is having a profound impact on communities and society. I am gravely concerned that some of these self-appointed counsellors are preying on communities. Often, in the event of a tragedy - not always a suicide, but perhaps the tragic fallout from a murder or other event - signs appear at the back of churches and in community centres. It is of great concern. I do not doubt the Minister's bona fides, but has HETAC been instructed in some way to come up with solutions to the best of its ability, or has it merely been asked to do so? It is under pressure and I know that trying to bring about qualification standards can take a very long time.
I understand the Minister's problem, but is there any way in the meantime that a system can be put in place which forces non-professionally-recognised groups to advertise the fact they are not professionally recognised until something is put in place?
To address Deputy Kelleher's issue, I agree 100% with his sentiment. HETAC has been formally asked to examine and address this issue and to come back with a report and give us a standard qualification that people must meet. This is what everybody in the room is concerned about.
With regard to Deputy Dowds's question, I do not think his request is in my gift. It would require a legal change and I would have to speak to the Minister for Justice and Equality and the Office of the Attorney General on whether it is possible.
We will do so on Report Stage. I will report back on the advice we receive from the Department of Justice and Equality and the Office of the Attorney General.
With regard to Deputy Ó Caoláin's concern about speech and language therapy, this is a major problem and something which also applies to physiotherapists. They achieve 550 points in their leaving certificates and study for four years but end up working in McDonald's or leaving the country. I have been in discussions with the Department of Social Protection about establishing a JobBridge programme to allow them get a year's experience in the community. Even though colleges will state these are fully trained physiotherapists, it is a bit like the intern year; one might be finished one's qualification, but one needs practical experience in the community also. We are trying to work on this. As the Deputy rightly said, people are screaming for physiotherapists and speech and language therapists. We need them in the community and there is the capacity to have them engaged through mechanisms other than being directly employed by the State to make their services available to people. We are certainly addressing this. I share the Deputy's concerns.
Even if the committee were to vote through this amendment and force it upon me, what would I call the people involved? Under what heading would I put them in this grouping? Psychological therapists is not a legal term.
Technically, I am hidebound. We must reach agreement on a protected title for these people and a basic standard qualification. Then we can move this very quickly. I will do everything I can with regard to the Department of Health and the Department of Education and Skills and HETAC to get this expedited.
In 2008 a committed Minister of State, John Moloney, made the very same commitments as the Minister, but the system frustrated him. It has not happened for five years. How can I have confidence the system will do it before 2014?
The Deputy would have to ask Mr. Moloney. I do not know.
This Government will be in office for at least three and a half more years, during which time members will have an opportunity to bring to me to task on this on a regular basis, which I welcome. Like others, I want to see this expedited. It is true that the wheels of government can be frustratingly slow at times. However, we are increasingly finding ways to speed them up and will continue to do, in particular on this hugely important issue.
I will outline my concerns in relation to both issues. As I understand it, the cost of joining a professional body varies greatly. I believe that cost should be as low as possible. While I recognise, given the changing nature of the world, that it is important to have a body for each profession, I do not understand the reason the fee in this regard in the social work area is €250 and the teaching area is only €90. Perhaps the Minister would address that issue.
In regard to the second issue, I understand that the Bill addresses the issue of language, specifically the ability to use the English language. This is an area in which we have been very lax. We have allowed people who do not have competence of the English language to work in all types of areas. What measures will be in place to ensure that anyone working in a given profession will have competence in the English language?
I, too, have concerns about the two issues raised by Deputy Dowds, although I will try not to repeat what he has said. I would welcome the Minister's opinion on the following matter. Where under the registration requirement, a person who is qualified as a social worker, speech and language therapist etc., but who may be working as a youth worker rather than a social worker and so on, how will this impact on his or her registration? Much of this morning's conversation, which I welcome, has been around how we protect users, which is very admirable and how it should be. However, we also have a responsibility to ensure the professionals are not downgraded. For example, how will this impact on a person who has been a Member of the Dáil for, say, four or five years who was previously a registered social worker or speech and language therapist? How can we ensure it is possible for such person to re-register? The emphasis on registration is not alone about protection but about the ongoing professional development of the various disciplines to ensure they can meet the needs of and produce the best outcomes for the people who come before them.
In regard to language competence, communication is an integral part of how we engage with people across so many disciplines. I am concerned about how the legislation proposes to address that issue.
I will deal first with Deputy Conway's issue. I am aware the Deputy was formerly a social worker. I am sure the Deputy is equally aware I was a GP for 25 years. As such, I can speak at a personal level about this issue. I removed my name from the medical register for the reasons outlined by the Deputy, namely, I did not believe I could do my current job and also maintain my continual professional development and standards. I, therefore, withdrew from the medical register. If I wish to re-register, I will have to retrain. What that retraining will entail, I am not sure. The Medical Council will determine that to ensure that I am a fit person to treat the public again. The same will apply to social workers and any other profession in this area. We are all agreed that it is unlikely that a person involved full time in politics for a long time will maintain his or her skill set.
What if the person is working in a related profession but it is not called social work? For example, a person working for Barnardos or Childline may be known as project or youth worker rather than a social worker. What will happen in respect of the underlying qualification? A person could be a social care worker and doing work that is relevant in that area but not be working as a social care worker. It is an issue which needs further consideration.
The person will have to achieve a standard that allows him or her to be listed on the register. Where the person does not achieve the standard he or she will be able to get on the register and there ends the matter. Section 7(a) and New Section 38(1) provide that a person returning to practice must satisfy the registration board that he or she meets the criteria and fulfils the conditions in this regard. In other words, the person will have to again prove his or her competence.
With regard to fees, I spent a great deal of time on this issue. When the matter first came across my desk the proposed fee was €380. With no disrespect to the people concerned I wondered if it was about empire building. The €295 fee is a reduced fee. Looking at the economics of this, the fee should be closer to €380. As to the reason the fee is higher in some areas than it is for teachers and nurses, the answer is obvious. There are 60,000 nurses and tens of thousands of teachers. Running an organisation requires payment of fixed overheads. The medical registration fees are in excess of €1,000. The level of fee comes down to the volume of work, etc. Another factor is the amount of litigation which a body would be required to handle. It is akin to a quasi-judicial process.
On the language issue, that is something which I take seriously. While I have a note before me on the issue I will try to give Deputy Dowds a response specific to my own previous profession. I always found it astonishing that while some people with no basic English can come here on the basis that they are EU citizens people from South Africa, America and Australia, whose first language is English are required to undergo a language test. It is bizarre. We are addressing that issue with the Medical Council.
Yes. I am coming to that. Section 7(b) amends section 38(1)(d) to provide that all applicants for registration must satisfy the registration board that they have the language skills necessary to practise.
Yes. A language examination cannot be imposed systematically but if a competent authority has concerns that an applicant does not demonstrate appropriate language competency, it may seek such a test. Language testing may in certain cases be one of several requirements for registration, along with, for example, qualifications, recognition, fitness to practise or fee payment, as prescribed in section 38(1)(d). It is covered.
I agree on the language issue. I have come across a psychiatrist who did not have proper language skills. Communication in the psychiatric profession is vital. I have heard complaints about patients and families who hardly understood what a psychiatrist was saying.
The Deputies are correct as communication goes beyond language. Much is lost but there is a balance to be struck between the value brought to other countries by training people and working here, and what our people get from going to other countries to train. In the main, it is regrettable that we have trained Irish doctors and nurses who then go abroad while we are taking doctors and nurses from Third World countries which need them far more than us. We are trying to address that issue through the new entry level of consultants, meaning we can employ more consultants at an earlier stage. It makes no sense that three out of four specialist registrars leave this country when they finish their training because they cannot get a job. It costs the guts of €1 million to bring those people to that point of professional development.