Dr. Donal O'Hanlon:

I thank the Chair, Senator Freeman, and members for the opportunity to address them on the significant challenges facing the mental health services and specialist psychiatric care in particular. The IHCA represents 85% of all hospital consultants working in Ireland’s acute hospital and psychiatry services. This statement is a summary of the detailed submission provided to the committee in mid-January, which I assume members have received.

Ireland’s spend on treating mental illness is approximately half that of most northern European countries, at just 6.6% of the total health budget. We have yet to implement many of the recommendations of the Government’s 2006 mental health policy, A Vision for Change, with shortfalls across a spectrum of areas, including bed capacity, community care services and staffing. The IHCA shares the committee’s concerns that access is a vital factor to consider when examining each of the three high-level themes it has identified, namely, primary care, recruitment and funding. The association agrees that while primary care is well positioned to provide care to service users and patients with mild to moderate psychological problems, those with moderate to severe illness often require specialist psychiatric care provided by hospital-based consultant psychiatrists. Unfortunately, we do not have the resources or the number of consultant psychiatrists required to provide high quality, timely care and treatment to patients who need it.

The Hanly report in 2003 and the HSE national doctors training and planning unit in 2014 recommended that the number of approved consultant psychiatrist posts be significantly increased to 712 by 2016 and to 755 by 2024, respectively, to ensure that safe and effective psychiatry services can be provided on a timely basis.

Additional increases have been recommended, up to as many as 858 consultant psychiatrists by 2020, by the College of Psychiatrists of Ireland. This represents more than a doubling in current numbers. A further workforce concern is that of the existing 418 approved consultant psychiatrist posts, of which only 290 are permanent appointees.

Our psychiatry services in particular fall significantly short of the recommendations in A Vision for Change and in comparison with other European countries in terms of consultant workforce, bed capacity and funding.

Ireland has 6.1 consultant psychiatrists per 100,000 population, just half the EU average number of specialists and one third to one quarter the number in many EU countries. Ireland is ranked below such countries as Romania, Slovakia and Greece, and has 22% of the number of consultant psychiatrists in Finland for a comparable population.

The prolonged and deepening consultant recruitment and retention crisis is due to the failure of the State and employers to honour the 2008 consultant contract and the imposition of discriminatory terms and conditions on new entrant consultants. This has been exacerbated by the steep financial emergency measures in the public interest, FEMPI, cuts applied to consultant salaries and systemic funding shortfalls in the psychiatry services and mental health services during the past decade.

The Irish health service is uncompetitive in recruiting and retaining the number of high calibre consultant psychiatrists it requires. This sharp decline in competitiveness is evident from the fact that 31% of all approved consultant psychiatrist posts at the end of 2016 were either vacant or filled on a temporary basis. Nearly three quarters of temporary post holders, some 37 of the 51 staff had agency contracts, thus increasing the overall costs to the health service.

More recent figures released in October 2017 confirmed that of the 201 approved consultant posts, in all specialties known to be filled on a temporary basis, psychiatry accounted for a disproportionate number of posts, some 50 posts or a quarter of the total.

A quarter of consultant psychiatrist posts advertised in 2015 and 2016 had no applicants, with 30% having only one applicant for the vacancy. This recruitment crisis has also manifested itself in the appointment of 21 non-specialists to consultant psychiatrist posts across psychiatry specialist areas as follows: 15 non specialist to general adult psychiatry; four to child and adolescent psychiatry; one to psychiatry of old age and one to learning disability psychiatry. This undermines the safety and quality of patient care and is in breach of the HSE’s recruitment rules and the Medical Practitioners Act 2007. These breaches have occurred across the country in Carlow-Kilkenny, Cavan-Monaghan, Clare, Donegal, Kildare-West Wicklow, Longford-Westmeath, Mayo, Midlands, Sligo-Leitrim and Tipperary south.

Ireland is not self-sufficient in the provision of specialist trainees, as we are not training enough to meet the requirements or replace current numbers, particularly given the difficulties in retention at non consultant hospital doctor and consultant levels.

Shortfalls in community team staffing levels are restricting the services' ability to deliver care to users and patients. The staffing deficits compared with levels recommended in A Vision for Change are up to 68% in intellectual disability services for adults; 47% in child and adolescent mental health services, CAMHS, 42% in psychiatry of old age services and 22% in general adult psychiatry teams.

Ireland has the third lowest number of inpatient psychiatric care beds in the EU, with 34.83 beds per 100,000 population. This is half the European average, and the bed capacity has declined sharply from 101 beds per 100,000 population in 2004. This has occurred at a time when Ireland’s population increased by more than 500,000 during the past 12 years, and while those aged 65 years and over increased by 35%. While A Vision for Change planned for a marked reduction in acute psychiatric hospital beds, the promised alternative services have not been provided in the community.

The number of adult psychiatry inpatient places available for acute admissions, 972 acute adult inpatient beds at the end of 2016 has been reduced to the point where there are frequently no beds available at night in many community healthcare organisations, CHOs.

Given that there are only four CAMHS inpatient services nationwide, located in Dublin, Galway and Cork, children often have to make 400 km round-trips from their homes in order to access treatment, thereby experiencing significant separation from their family, friends and school.

Furthermore, there is no co-ordinated national system to resolve crisis situations when they arise. This presents a significant patient care and safety issue.

The admission of children and adolescents to adult psychiatric units is a totally unacceptable but common practice, with 68 children admitted to 19 adult units in 2016. A third of those admissions to adult units were in one region – CHO 8, which encompasses Laois-Offaly, Longford-Westmeath and Louth-Meath. While this represented a 29% decrease on the number of such admissions in 2015, the admission of any child to an adult service is most unsatisfactory. The downward trend may be reversing again based on available data for the first five months of 2017, as 44 children were admitted to adult units compared with 36 for the same period in 2016.

The relatively low number of child and adolescent psychiatrists and the shortage of required front-line resources has resulted in unacceptably high numbers of children on CAMHS waiting lists. In September 2017, 2,333 children were waiting for their first appointment, with 1,472 waiting more than three months to be seen, an increase of 42% compared with October 2016. The number of children waiting more than a year has also increased significantly from 170 in September 2016 to 317 in September 2017. This is all against the background of a 26% increase in CAMHS referrals between 2012 and 2017.

There were also only 29 teams for psychiatry of old age in place in 2017 compared with the recommended 39 teams recommended in ‘A Vision for Change’. The HSE projects that referrals to psychiatry of old age will increase by 17% between 2017 and 2020.

These deficits are not surprising, given that the 2018 mental health budget of €917.8 million is 10% below that allocated in 2009, which was€1,022 million. As previously mentioned, Ireland's spend on treating mental illness is approximately half that of most northern European countries, at just 6.6% of the total health budget. Designated, ring-fenced funding for specific clinical programmes in psychiatry is required to provide early intervention for first episode psychosis, the comprehensive treatment of eating disorders, and self-harm presentations in emergency departments. Resources are also required to support the overall management of the services by executive clinical directors.

Moreover, there are substantial regional disparities in the allocation of funding and resources, with community healthcare organisations, CHOs, of similar population size allocated significantly different budget allocations and staffing.

The above deficits are contributing to significant access problems in the acute psychiatric services, as demonstrated by the persistent and damaging long waiting times for treatment and the unavailability of specialist services promised in A Vision for Change.

The association welcomes the work of this committee on implementing a single, long-term vision for psychiatric care and the direction of mental health policy in Ireland. I thank the committee for inviting the association to its discussion today. We are available to address members' questions on the above and the contents of the association’s submission.