Mr. Michael Walsh:

I thank the Chairman and committee members for giving me the opportunity to give an account of what it is like to work on the front line of child psychiatry and to highlight the issues that will face us in the future. I am not representing the Health Service Executive, HSE, and my address to the committee is without prejudice. I am a clinical nurse specialist in south Wexford CAMHS. I have spent the past 25 years working in CAMHS, the first 15 in the north east, serving counties Cavan, Meath, Monaghan and Louth, and the last ten in Wexford. In that time I have watched CAMHS teams develop throughout the country , from seven nurses nationally in 1993 to approximately 120 working in community CAMHS teams today. The number of CAMHS teams has grown from zero outside Dublin in 1993 to 69. When I speak about teams, I mean the teams recommended in A Vision for Change in 2006 - one team per 50,000 head of population, consisting of one child and adolescent consultant psychiatrist and, under the direction of this consultant, one junior medical staff member, two psychologists, two social workers, two clinical nurse specialists, one speech and language therapist, one occupational therapist and one social care worker. That gives a multidisciplinary team of 11 staff, which also requires one secretary and one administrator. This skill mix is a must to adequately address the clinical needs of the varied and very complex clinical presentation of the children we are asked to see.

There is a population of approximately 80,000 in my area of Wexford south. We do not meet and have never met the standards in A Vision for Change. We have one child and adolescent consultant psychiatrist, although we should have two for a population of 80,000; two clinical nurse specialists where we should have three; one psychologist instead of four; one basic grade social worker instead of a principal social worker, plus two basic grade social workers; one occupational therapist and 0.5 of a speech and language therapist where we should have one operating full time; 0.5 of a social care worker where we should have two.

We operate on a clinical need basis; urgent referrals are seen as a priority. Routine referrals are placed on a waiting list to be seen. Ours is a very hard working and committed creative team, like all CAMHS teams across the country. We get involved in projects in the community, set up groups to enhance treatments such as parenting groups for ADHD, activity groups and dog walking groups, to mention just a few.

The role of the child and adolescent health team is to assess and treat children at the severe end of the scale such as those with early onset schizophrenia, depression, anorexia nervosa, ADHD and severe anxiety. During the years many children and families have benefited from our input.

As a team, we struggle every day to overcome many obstacles, including being under-resourced; having poor accommodation which is not fit for purpose; having no consultant cover for consultant leave; difficulties in recruitment and the retention of staff and having no ability to facilitate the training of student nurses. The accommodation at Slaney House is substandard and not fit for purpose. A review of the building in 2006 pointed to 25 issues that needed to be addressed to bring the building up to standard. Some of these issues were first addressed in 2015 when it received its first coat of paint in 14 years. The building was a residential house and it is neither clinical nor child friendly. Five staff members share one room measuring approximately 6 m by 4 m. There are no facilities to carry out physical examinations which are necessary to start clients on medication. Accommodation was to have been secured in 2017. October 2017 was the move-in date. We were all very excited at the prospect of having more rooms to provide therapy, engage in group work and the possibility of developing a full child and adolescent mental health service. There was also the possibility of developing a day programme to support clients who could not be given an urgent hospital bed or clients who were not attending school owing to illness and those in need of a greater therapeutic input. We were informed by management that the proposed building was to have another tenant, but it could not inform us who. That was the last we heard about being given suitable accommodation.

The second problem I experience as a front-line worker is that of having no consultant cover. Our consultant child and adolescent psychiatrist is entitled to his leave, like the rest of us, but he is the clinical lead for the team and takes full responsibility for all of the patients who attend the service and their treatment. When he is on leave, there is no replacement; hence no new referrals are examined and no new clients are seen. As per An Bord Altrainis and the standard operating procedure, I, as a nurse, cannot see clients without a clinical lead, nor can the junior doctors. To work safely within my scope of practice, planned reviews must be cancelled during this time. For seven years I have been bringing this issue to the attention of management at all levels, including sending the reason children needed to be seen to them via email. Some children have been admitted to Wexford General Hospital for a week or more as a result of there being no consultant cover where they spent their time without any therapeutic input. However, that problem has changed in the past six months as an out-of-hours adult psychiatrist provides an assessment and treatment for the children admitted in the absence of a proper hospital liaison child and adolescent team as per A Vision for Change in 2006, that is, one team per 300,000 people.

My direction from management in the absence of a consultant child and adolescent psychiatrist is to work within my scope of practice and contact management should a child require a consultant assessment. It took two weeks the last time I needed this facility for a child who needed an urgent assessment. It required several requests by me before it was followed up. As a nurse, it is very frustrating to listen to distressed parents who are seeking help for their sick child when I cannot offer the service I offered the previous week. We lose the trust and credibility we work so hard to earn by not being able to offer a service. The parents tell us that there is no consistency in the service. As research has shown, consistency is the basis of all therapeutic interventions. This is not to mention the frustration of general practitioners who telephone CAMHS seeking a service during the consultant's absence. As a nurse on the front line, I should be able to go about my work without having to look for a consultant. I have received numerous calls from upset parents owing to cancelled appointments.

Most of the consultant child and adolescent positions in the country are filled. There are 69 teams, but, to the best of my knowledge, 35% of the consultants are locums, posts filled by agencies. As the committee heard from previous speakers at this forum, it is difficult to find child and adolescent consultant psychiatrists owing to the two-tier salary scale. However, consultants on agency rates receive the same salary as, if not more than, the permanent consultant. Therefore, it does not make sense to have a two-tier system.

My reason for bringing this to members' attention is that nurses who wish to progress and become acting nurse practitioners or wish to take the nurse prescribing course cannot do so in 35% of CAMHS services as the consultant is required to work with the nurse in taking the said course. Hence, a failure to provide a permanent child and adolescent consultant psychiatrist is preventing nurses in CAMHS from progressing on their career pathways.

On the recruitment of nurses to CAMHS, in Wexford south CAMHS we cannot take student nurses as there is not enough room in the building. We cannot offer consistency in that we may not have consultant cover for the period of the student placement. The knock-on effect of taking no students is no exposure to child psychiatry; hence nobody trains in the access module to child psychiatry. One nurse took the course two years ago and there has been none since from the south east. Some of the students who in the past sought placement in CAMHS are now working in London. They have informed me that they are well remunerated for their work, with accommodation packages and access to training courses such as nurse prescribing and family therapy. When asked whether they would return to work in Ireland, their answer was a very clear "no". They said they had already been treated badly following their qualification when they were given 85% of staff nurse wages.

Following discussion with my colleagues from around the country, many are reconsidering the positions they hold in CAMHS. Some have already left and are going to Canada, Australia and Britain. Given the deals nurses are being offered elsewhere, it would be hard to refuse, considering that we treat our newly qualified as "yellow packs" by offering them substandard wages. Even if we were to provide 500 more places in nurse training each year for the next three years, how many would remain in the country? Given the poor working conditions, poor pay and the fact that they are totally undervalued, there is no incentive to stay. In 1999 the commission on nursing made provision for nurses like me to stay in a clinical role and not to move into management. My colleagues and I endeavoured to educate more nurses in CAMHS, but owing to our working conditions, this was not possible.

Children seen by GPs are referred to CAMHS in the absence of a properly resourced primary care psychology, autism or disability service. Wexford autism and disability services have a two-year waiting list, while Wexford primary care psychology services have a two-year waiting list. These services do not work on clinical need, but CAMHS ends up receiving more referrals as a result. Our nearest inpatient hospital is over 200 km away in Éist Linn in Cork. It is not the case that when a child presents with a significant suicidal risk we can send him or her directly to Cork. It is often the case that the child is kept at home by the parents and monitored on a daily basis by CAMHS. Access to a bed may take three to four weeks. Sometimes, if the child's condition deteriorates and he or she cannot be managed at home, he or she, as has happened in a number of cases, is admitted to the department of psychiatry in Waterford. It is an adult psychiatry facility and no place for a child. While there, a child is confined to a room on his or her own, accompanied by a psychiatric nurse and not allowed out of it during the hours the adult patients are moving around the facility. It is my opinion that this simply contradicts what is in "the best interests of a child".

We are all here to look at how best we can provide a service for those less fortunate than ourselves. In my case, these are the children between the ages of six and 18 years who suffer from a mental illness. Children commit suicide. There were 70 children of schoolgoing age who took their own lives last year. This does not account for the children between 16 and 18 years who were not at school. We have a long history of not looking after the most vulnerable in society, from the Tuam mother and baby home, to Artane, the Magdalen laundries, Letterfrack industrial school and Wexford, where we had the Ferns and Monageer reports, to mention just a few. We are again letting down the most vulnerable children in society.

We need A Vision for Change to be completed. We need nurses to be paid at therapeutic grade level to keep them in the country. We need a hospital liaison service and consultant cover. We must realise that if we treat children with psychiatric problems when young, the vast majority will not need treatment as adults. We need to stop embargoes on the recruitment of front-line staff. Perhaps the embargoes should be placed elsewhere. Those who manage the services should be held to account. In a therapeutic role, if we are doing something that is not working for a child, we must stop and come back with a different idea. The management system where I work seems to be doing more of the same when it is not working. CAMHS should have an input at management level. We also need access to emergency beds for children. The Constitution states children should be cherished. It is our duty to implement this right and look after children.

I thank the committee for listening to my submission and welcome its work in forming a direction for mental health services in looking after children in the future.