Mr. Ger Reaney:

That is a very comprehensive range of questions. I will do my best to be brief.

Regarding the targets in A Vision for Change and how our teams compare, I agree with the Deputy's analysis of CAMHS teams. I think we are closer to the indicative figures for CAMHS in A Vision for Change than for adult services overall. We are at just under 90%. Approximately a third of our adult teams have the staffing they should have in terms of A Vision for Change. I should say, though, that A Vision for Change specifies an indicative staffing for a population of 50,000. Many of our teams have populations different from the 50,000 level. What we have, therefore, is analysis that is mathematical and does not necessarily take into account the mix of roles within the teams or local factors, whether geography, deprivation or whatever else. As for where some areas are over and some areas are under target, Killarney, which is the south Kerry team, is an area where the population is significantly dispersed and where significant travel is required to reach Cahirciveen and Waterville, whereas Tralee's is a more concentrated population. The variation between the teams is probably justifiable.

To respond to the question about whether it would be sufficient if the numbers in A Vision for Change were in place, it would be significant progress. It would be the realisation of a target that was set ten years ago at this stage. That target was designed to build up community services and minimise the requirement for individuals to attend acute units. Whether or not it would be sufficient would have to take into account factors to which my colleagues and I have referred regarding increasing evidence in modern society of pressures. This would probably require a greater buildup of services in primary care, to which the Deputy also alluded, and I might come back to that. Our initial target is to focus on achieving the targets in A Vision for Change, but I know that a review of A Vision for Change is under way and I suspect further development on those targets is required. Our current priority is the child and adolescent mental health service, which is furthest away from those targets, and some of the specialist services, which we are building up in terms of old age, mental health, psychiatry and rehabilitation teams.

We do recruit to the NRS, and we recruit otherwise as well. Our recruitment challenges are in particular areas of psychiatry, most non-consultant hospital doctors and psychologists and specialists nurses. We have 12 nursing vacancies out of a total pool of close to 400 staff. That is not a huge number at a given point in time but, regarding child and adolescent psychiatry, as my colleagues would have outlined to the committee in the morning session, we are working within both a national and an international shortage. We advertise those posts in The BMJ. More importantly, we follow up through individual contacts because the child and adolescent medical community is relatively small and, rather than do recruitment fairs, we feel this is probably at this stage a more effective process, and we are being successful. Our difficulty in Cork and Kerry is that we had a number of retirements coming quite close together and we have also had a number of people who are not Irish nationals and who moved to other countries. We have been quite successful. We currently have 1.5 positions to fill. We are confident of filling one of those positions and the other position will be advertised shortly.

Mental health services are one of the biggest users of psychology. In Cork and Kerry we employ nearly 100 psychologists, including some assistant psychologists, and we have recognised and led the way, working with UCC, in addressing what is a shortfall in training. Working with UCC and the HSE nationally, we have put in place a doctorate programme in psychology which will produce the first graduates in 2019, I think. That is our future plan for that area. In addition, our psychology department would be seen as being quite proactive and quite attractive to work in, but we are working within a pool which is not quite large enough.

I outlined the position regarding primary care earlier. We will go through in a little more detail some of the services that are available at primary care level. Key among these is the counselling primary care service, which is a national service. We provide that across 30 locations in Cork and Kerry, so it is locally accessible and GP-referred. It is fixed-term, usually six to eight sessions, and can be extended if necessary. We have two SCANs who cover three of our mental health teams in Cork and we are employing one nurse in Kerry from 2018. That service requires further development. The service is well integrated with GPs. Referral is made by GPs, and the nurse carries out an assessment, determines what form of service is required and provides feedback and information to the GP afterwards.

I have referred to our psychology service. Our primary care psychology service in Cork and Kerry has been under-resourced for some time and we have been proactive in negotiating with the national primary care division funding to improve this. I outlined the numbers earlier - seven psychology positions and 16 assistant psychology positions, the majority of which we have now offered to people.

The broader area of integration is a good one, and I feel there are opportunities for closer integration between mental health services and primary care services and between mental health services and other services. Some of this concerns building up our staffing, having more counsellors available through our counselling and primary care service, having more SCANs available and building up our community mental health teams, but also the structures. I referred earlier to community health care networks, with which members will be familiar from the Sláintecare report. They provide a format for closely integrating primary care services with other services, including specialist mental health services. I would be happy to elaborate on this should the committee require me to do so later on.

Regarding emergencies, no more than the Deputy, I have got the phone call late at night as well. Our preference, depending on the emergency, is to talk to someone's GP. The call that I took involved establishing whether the matter needed to be dealt with immediately or whether it could wait until the following day, and we established contact with the person's GP the following day.

If a service needs to be dealt with at night, we currently have over seven nursing service across most of the area and will have it across all of Cork and Kerry from April 2018 so that will be a port of call in an emergency. If an emergency occurs at night, the service that is available is the local emergency department. I appreciate that this is not the ideal service but we have built up liaison services, particularly in both of the major Cork hospitals, at medical and nursing level in recent years to ensure that this experience is as effective as possible.

In respect of dual diagnosis, it is hard to comment on the individual case discussed by the Deputy but I would not believe that normally addiction should be the reason that somebody would not be able to engage with mental health services. We have a strong addiction service in Cork and Kerry that is separate from our mental health services. Traditionally, it would have been within the mental health services but it works very closely with mental health services. We are seeking funding through our social inclusion budget nationally for a specialist consultant post involving a psychiatrist with an interest in addiction services. There are strong links there are and I am happy to discuss any individual cases that undermine that with the Deputy later.

The Deputy's next question related to suicide and the initiatives in place to address that. Obviously, suicide is an issue that is broader than mental health services. The health services have a role in providing a lead in the area but addressing suicide, be it in Cork, Kerry or across the country, requires society as a whole to work together. Obviously, members will be well aware of the increased profile and freedom to talk about mental health issues and that the national HSE "Little Things" campaign through social media and traditional media is significant. Locally, we have two plans, one for Cork and one for Kerry. They have 72 actions and multi-agency plans agreed with the local authority, the Garda and ourselves. We have suicide awareness officers who work on two fronts, one of which involves building community resilience working with communities and schools to raise awareness and building that community awareness and capacity to minimise the risk of suicide. We have trained 12,000 people in the SafeTALK programme, which, again, builds that level of capacity. The second focus for the suicide awareness officers is being there as a response when a suicide affects a family or particularly if there is more than one suicide in a community. We work with our psychology department in putting in place a number of resources to avoid what can be seen as a cluster effect at times.

The counselling we employ through mental health services is through the counselling and primary care services. That is provided through a third party agency at the moment which employs those counsellors. I cannot tell the Deputy the exact accreditations they use but there is an accreditation form. I am well aware that national accreditation standard will be set with CORU for counselling shortly. The Jigsaw service, which we fund, employs counselling psychologists but the counselling resource we employ directly would be psychologists and assistant psychologists. I think that answers the majority of questions.