Professor Guatam Gulati:

I thank the committee for the invitation to attend this meeting. My evidence will relate to my individual viewpoint as a clinical academic and does not represent the views of the HSE or any other affiliation.

The Irish ratification of the UN Convention on the Rights of Persons with Disabilities, UNCRPD, in 2018 enshrined the rights of people with disabilities in an international convention, providing much-needed momentum to reform of this area. This is particularly the case for people with psychosocial disabilities and people with intellectual disabilities. Article 19 recognises the equal right of all persons with disabilities to live in the community with choices equal to others. The report of the HSE working group on congregated settings in 2011 made a compelling case for urgent action in this respect.

Data from the implementation group recorded a 30% reduction in the number of residents in congregated settings between 2012 and 2017. However, a report in 2018 by Inclusion Ireland raised concerns about limitations in the scope of policy and rate of progress in deinstitutionalisation. The report raised the issue of people with disabilities moving between institutions, stating:

For example ... in 2015, less than 10% moved into their own home. Almost three quarters of those who moved actually moved to other institutions.

Against this backdrop, I intend to share a specific viewpoint with the committee relating to people with psychosocial and intellectual disabilities and the intersection of Articles 13, 28, 11 and 19 of the UNCRPD in respect of a process referred to as trans-institutionalisation. Trans-institutionalisation refers to a process whereby individuals who community care policies intended to deinstitutionalise in practice ended up in different institutions rather than their own homes.

I will briefly speak about people in prisons, people who are homeless and people who are seeking asylum. In terms of people in prisons, against a backdrop of the closure of a substantial number of psychiatric beds, a study that evaluated publicly available Irish data from 1986 to 2010 found an inverse relationship between psychiatric admissions and prison committals.

More specifically, this study found an increase of 91 prison committals for every 100 psychiatric hospital admissions foregone. There is a lack of up-to-date Irish data in respect of people with psychosocial disabilities in the criminal justice system. However, the available data suggests that approximately one in three prisoners screen positive for intellectual disabilities, one in two for substance misuse and dependence and that the prevalence of severe mental illness in Irish prisons is four times that of the general population. This is borne out in clinical practice where it is not unusual to come across individuals with multiple disabilities, including intellectual and psychosocial disabilities, in a prison setting. It is also possible to trace a link to a paucity of community supports prior to incarceration. Furthermore, the provision of equivalent care for these individuals as set out in the Nelson Mandela rules is challenging, with systemic and legal barriers to diversion in Ireland. It is important to ensure that Irish prisons are not, in effect, emerging as congregated settings for people with psychosocial and intellectual disabilities.

In regard to people who are homeless, a recent study in Dublin funded by the National Disability Authority, NDA, in respect of people with intellectual and developmental disabilities found 145 individuals or families identified as homeless or at risk of homelessness. This represents one study from one region in Ireland. An Inclusion Ireland report, using 2016 census statistics, found that people with an intellectual disability represent 1.4% of the total population and 3.1% of the homeless population. The link with homelessness extends to people with psychosocial disabilities. A recent study in acute psychiatric inpatient units in one Irish region found that approximately one in three inpatients were homeless or had a history of homelessness. More than one in six people committed to Irish prisons are homeless at the time of committal and there is a link between disability, incarceration and homelessness. A 2012 Irish study found a high prevalence of psychosocial disabilities among people in a Dublin hostel for homeless people. Article 28 of the UNCRPD places a duty on the state to ensure equal access by persons with disabilities to public housing programmes. We need to ensure that hostels for people who are homeless are not, in effect, emerging as congregated settings for people with psychosocial and intellectual disabilities.

On people seeking asylum in Ireland, there are more than 7,000 people living in direct provision in Ireland, 30% of whom are children, with an average stay of 24 months. A study in direct provision centres in Sligo and Leitrim found that asylum seekers were six times more likely than refugees to report symptoms of post-traumatic stress disorder, PTSD, depression or anxiety. A study in a Galway primary care setting found that asylum seekers were five times more likely than Irish citizens to be diagnosed with psychiatric illness. Little is known about the prevalence of people with intellectual disabilities in the direct provision system. However, there is international recognition of the additional barriers people with intellectual disabilities face in the asylum process. Article 11 of the UNCRPD requires the state to take all necessary measures to ensure the protection and safety of persons with disabilities in situations of risk, including situations of armed conflict and humanitarian emergencies. We need to ensure that direct provision centres do not emerge as congregated settings for people with psychosocial disabilities.

Further to the McMahon report, the Government White Paper on ending direct provision is to be welcomed both in reference to housing and community inclusion. It would be important that people with intellectual and psychosocial disabilities are appropriately supported through this process to avoid a risk of trans-institutionalisation. Decongregation of people with disabilities from institutions can be positive. However, it must be accompanied with community supports and inclusion strategies to avoid a risk of trans-institutionalisation. The right of all persons with disabilities to live in the community, with choices equal to others and with full inclusion and participation is a basic right. Realising this in practice is a litmus test of our commitment as a society to the values of the UNCRPD. I thank the committee.