Professor Harry Kennedy:

I thank the committee for inviting us to this meeting. I have brought two colleagues with me: Mr. Peter Byrne, who is peer educator from the service reform fund and attached to the national forensic mental health service, and Mrs. Pauline Gill, who is general manager of the national forensic mental health service. I will talk about problems, causes and solutions taking the headings of the committee's terms of reference.

With regard to waiting lists for transfer from prison to the Central Mental Hospital, currently there are 28 on the waiting list and there are 323 on the caseload of the in-reach teams we provide to the Irish Prison Service. All of the people on the waiting list are urgent. All of them are severely mentally ill and should not be in prison. They have been on the waiting list for months and this is entirely unacceptable by any clinical standards. When we surveyed the numbers with severe mental illnesses in the prison population over ten years ago, we found there was a need then for approximately 350 secure forensic beds for Ireland. Matters have probably worsened since, although we have taken every alternative strategy as far as possible. I will list those as we proceed. We have tried to manage with minimal resources compared to other countries, and I can tell the committee what the averages in other countries are. Matters are managed only because the Irish Prison Service does not complete certificates for those who should be admitted until we have a bed available. One of the problems for all of us is that we manage to cope in increasingly difficult situations. Ultimately, that is not a great thing.

As clinical director I have statutory obligations under the Criminal Law (Insanity) Act. I am increasingly unable to meet my statutory obligation to admit those found not guilty by reason of insanity in the courts. Again, we cope by asking the courts to put off sentencing, for example. We have published the results of participatory action research showing how a systematic screening of people on reception in prison identifies those in need of psychiatric care. We have shown that we can identify those who need treatment and individual care and treatment plans. Most can be diverted back to community mental health services. We have now set up a model service, which is copied in other countries. We originally modelled it on the Australian system and now other people come to visit us. However, there is an irreducible number, those who are on our waiting list and those on our caseload, who cannot be managed in community mental health services or approved centres around the country. Those who are too dangerous to others because of their severe mental illness require treatment in conditions of therapeutic security.

The national forensic mental health service currently has 93 beds for adults in need of treatment in conditions of therapeutic security. That is two per 100,000 of the population of Ireland. This has not changed for many years. Comparable countries have between five and 14 secure forensic beds per 100,000. The Netherlands is at the upper end of that range. We will move to 130 adult medium and high secure forensic beds in Portrane in 2020, with an additional 30 intensive care rehabilitation unit, ICRU, beds which will now have to serve the entire country. That will give us 3.4 adult secure forensic beds per 100,000. Comparing like with like, most developed countries have between five and 14. We will also open ten forensic secure child and adolescent mental health beds on the Portrane campus, but obviously not within the adult campus. The new hospital will not bring Ireland up to international average resource levels.

On the need to meet long-term needs, because of the lack of a national plan to meet the needs of those requiring longer-term, slow-stream care, treatment, rehabilitation and quality of life in secure forensic hospital settings, and because of the continuous growth of this group, we think it will be necessary to plan for the introduction of designated centres, as a matter of desperation, in prisons. I entirely agree with what Mr. Donnellan has said. Looking at the global situation, this has already happened in the Netherlands, Finland and other progressive European countries even when much better resourced than we are. The Netherlands has the most forensic beds in the community and it is now opening designated centres in the prisons. We might discuss the root cause of this if there is time. There will also be a need for longer-term secure psychiatric beds within five years of the opening of the new Central Mental Hospital in Portrane. We can already foresee that the new hospital will not be enough and we would like to start planning the next step now.

According to the committee's terms of reference there was a consensus that the 2006 policy, A Vision for Change, charts the best way forward for mental health services. A consensus can be specific to its time or it can fail to address some important areas. Sometimes it can be wrong. A Vision for Change is now out of date because it could not take account of modern knowledge regarding, for example, at-risk states in the young and, because of its era, it could not take account of modern evidence for enduring neurocognitive impairment occurring during the prodromal onset stage of schizophrenia and other severe, enduring and disabling mental illnesses. For a proportion of patients these illnesses are now better conceptualised as developmental disorders and enduring disabilities.

A Vision for Change did not address the need for general adult psychiatric admission beds in an epidemiologically appropriate way. From EUROSTAT we know that, typically, other countries have between 40 and 60 general adult beds per 100,000 while A Vision for Change recommended 17. We managed to get it down to 20 before a halt was called. It also did not seek to examine international best practice regarding the use of such resources. A Vision for Change did not address the need for local psychiatric intensive care units, for example, as part of general adult psychiatry. Typically, other countries would have three such beds per 100,000. We have hardly any. The plan for four intensive care rehabilitation units in A Vision for Change was a compromise between the need for approximately 350 secure forensic beds, including secure slow-stream rehabilitation beds, and the acute general adult psychiatric local intensive care beds, PICUs.

In the event, neither has been prioritised. A Vision for Change recommended that general adult psychiatry should reduce to 17 beds per 100,000 based on an ideological and frankly faith-based belief that acute, sub-acute and rehabilitation treatment for severe mental illness could be done in the community. This missed evidence that even countries with well-developed community services still have 40 to 60 beds per 100,000 for general adult psychiatry. EUROSTAT shows us these data. Countries such as the Netherlands, Germany and the Scandinavian states, which provide the most progressive community services, provide choice. They also have inpatient services. No research has shown that community services work as an exclusive option. In practice, in many countries, including Ireland, the only way to obtain treatment for more than a week or two and longer-term intensive care packages in the community is to access these through the criminal courts.

Eleven years after its publication, A Vision for Change is not yet fully implemented. All those aspects of A Vision for Change that removed or diverted resources for mental health services for severe mental health were implemented. Those that transferred resources into the planned community services were not fully implemented when they cost money - revenue - or manpower. Resources - revenue and manpower - have been lost to services for people with severe and enduring mental illness. I suggest that now is the time for an entirely new document, not a revision of an old document.

The joint committee might want to try to achieve agreement on the best rational, scientific and clinical evidence for effective services that achieve human rights, including rights to dignity, rights to health and rights for disabled people, including quality of life, for people with severe mental illnesses, particularly those with enduring impairments of functional mental capacities due to mental illnesses or intellectual and developmental disorders, for people in need of long-term care and treatment in conditions of therapeutic safety and security due to the danger they present to others, and for people who do not present a danger to others. There should be some effort to engage and develop the health and justice interdepartmental and inter-agency consensus about the relationship between individual freedoms and the protection of others. My colleagues - psychiatrists and other mental health professionals who work closely within the criminal justice system - and I are continually concerned about the exercise of bail for those who are a danger to themselves. There is a lot of evidence that suicide rates are high among those bailed - higher, curiously enough, than among those remanded in custody. There is also a concern about the exercise of bail for those who are a danger to others.

Regarding the current integration of delivery of mental health services in Ireland, there are problems with integration of services due to the emphasis on local delegation of responsibilities without delegation of competencies. The failure to develop PICU units locally is the most obvious of many examples along with the rejection of those who become homeless, which is a continuing problem for us at the transition between criminal justice and mental health, between custody and the community. The rejection of those who become homeless is an obvious failure of the catchment area system and the substantial lack of beds and community mental health teams that could be corrected at least in part by empowering central direction and, if necessary, by legislating for central directors of services.

Many other states the size of Ireland have so-called clinical chiefs or heads of psychiatry who are the ultimate line managers of all psychiatrists and can direct colleagues to accept patients who are otherwise unable to obtain services. Ireland urgently needs an office of chief psychiatrist, comparable to those in states in Australia, with the power to direct that no one is deprived of rights of access to mental health services and, where necessary, to drive resource allocation. This would include an oversight of evidence-based and effective services of equal quality, accessible equally to all, around the life cycle. The office of chief psychiatrist would integrate heads of all disciplines and ensure co-ordinated manpower planning and multi-annual planning of service delivery, all things that are missing at the moment.

The office of chief psychiatrist should be independent of the Mental Health Commission and should have the ability to exercise executive power. It should not be merely an advisory position. There are such advisory positions, which have a role in their own right. This would solve the problem of preventing rejection and ensuring provision of mental health and substance misuse services for those leaving prison, an important group among the homeless. Co-operation with primary care, disability and welfare services would be an added task since this does not work as well as it ought to.

The commissioning of regional and national tier 3 and tier 4 services should also be under the central direction of an office of a chief psychiatrist which should include chiefs of other clinical disciplines and should be supported by managers. This office of chief psychiatrist should also be responsible for the commissioning of service related research, development, teaching and training, which is a virtuous cycle that is essential for excellent services. This office should not be vulnerable to being starved of necessary resources. It could be said that the executive clinical director experiment was starved in that way.

I would suggest that a central office is needed. To achieve the availability, accessibility and alignment of services and supports to ensure the integration and seamless provision of services to children, adolescents and young adults during life cycle transitions and the transition from working age adults to older adults, the appropriate solution is a national office of chief psychiatrist with the power to direct local service providers, including consultant-led community mental health teams.

Regarding the need to develop prevention and early intervention services further, I must sound a note of caution with regard to prevention. The evidence is tenuous that severe mental illnesses and mental disabilities such as schizophrenia, bipolar affective disorder, autism and intellectual disabilities can be prevented. There is little evidence that any programme can prevent schizophrenia, autism or other disabling severe mental illnesses, although these affect about 1% of the population. There is better evidence that early intervention can reduce long-term disability, although even this requires further research and development specific to an Irish context. To be effective, this requires a shift to screening models from help-seeking models where a person is expected to present themselves to their GP or where their family might do that and it is hoped the person will escalate through the system to find what they need. In effect, this is what we do in our in-reach systems in the criminal justice system. We screen on reception. We are introducing the same in the youth justice service. There is also a requirement to set quality standards for "treatment as usual" and a rolling programme of randomised controlled trials of how to improve treatment as usual at national level. There is no consistency in what a person would get as treatment depending on where he or she happens to be.

Regarding at-risk mental states, in St. Patrick's Institution, which is now closed and which provided for those aged 16 to 21, we found through screening that 23% of young people on reception met clinical criteria for an at-risk mental state, which carries about a 15% chance of going on to develop a severe mental illness. These were strongly associated with poly-substance misuse, which occurred in the great majority of young people detained. We are now finding much the same in Oberstown Children Detention Campus, allowing for the younger age group. It is not quite so common in people who are younger. We have not been able to recommence screening there, however, partly due to difficulties recruiting a full team. I will talk about the system of recruiting panels compared with bespoke recruitment.

Regarding suicide and unnatural deaths in adult prisons, the suicide rate in prisoners is now lower than it was 20 years ago when it was the main impetus. We believe this is the direct result of the introduction of screening on committal and psychiatric in-reach and court liaison services, PICLS. PICLS is, again, picked as a model for other countries. In our most recent survey of coroners' verdicts, we found that unnatural deaths, including suicides, were strongly associated with the deceased having illicit intoxicants in the blood at the time of death.

We have introduced a pre-release planning programme, about which Mr. Donnellan spoke. We have now piloted a service for arranging aftercare packages for mentally ill prisoners on release from custody. The pilot at Mountjoy Prison has shown the value of this scheme.

We have taken what we can do in the prisons and in the community as far as we can. We have high-support units in Cloverhill and Mountjoy. We have screening systems on reception in almost all of the prisons. We have systems to divert through the courts those who can be safely cared for in the community or through local services. We have 323 people on our prisons case load today. This includes those who are sentenced and those who are on remand. We cannot accommodate those who are too ill for prison and we cannot admit them either.

A vital way to improve recruitment is to have a culture of excellence. The HSE must urgently shift towards a culture of clinical excellence. Excellence is inseparable from the virtuous circle of research, development, teaching and training. Only centres of excellence should be empowered to train postgraduate mental healthcare professionals. Ireland should be self-sufficient in all mental health professions. Manpower planning to date is difficult to understand. We struggle to attract the best trainees - or sufficient numbers of trainees - because the mental health services do not enjoy a reputation for excellence, unfortunately. I say that as someone who is within those services. The mental health services do not have a positive image as valuing health and welfare outcomes for patients. A part of the problem is that many trainees go abroad to broaden experience, which is a good thing, and are unwilling to return to work in services that do not provide resources or cultivate excellence. They are unwilling to return to work in services that do not provide resources to keep up with modern practice and are subject to periodic serious impairments in quality and staffing during economic recessions. Specialist niche services such as the National Forensic Mental Health Service should be able to conduct bespoke specialist recruitment. When we were able to do so, we were always oversubscribed. The HSE's generic panel system has been a disadvantage to us.

I suggest that the joint committee should make explicit recommendations based on current international standards and should support those who are working continuously to keep these standards up to date. These standards should be grounded in the evidence of clinical science and not merely on good ideas. Good ideas are never a guarantee of success. Expertise has a technical definition. Experts may be contributory, interactive or experts by experience. All of these are valuable, but they are different. A Vision for Change put itself forward as the report of an expert panel. I think it is important to know properly what expertise is. Only contributory experts can be held responsible for a standard of competence in their evidence. Interactive experts are people like managers, lawyers and journalists who learn expertise by talking to the contributory experts who are responsible. There is a complete divorce between responsibility and the exercise of any sort of influence. There is every chance that the mistakes that have been made in the past will be made again. The committee should have access to expert advisers who have contributory expertise. Currently, there are few if any expert advisers in the Department of Health concerning psychiatry or any of the clinical disciplines. The HSE has advisers on clinical programmes, but no directors. The committee should have regard to the meaning of expertise.