Oireachtas Joint and Select Committees
Wednesday, 22 September 2021
Joint Oireachtas Committee on Health
Mental Health Services: Discussion
Apologies have been received from Deputy David Cullinane and Senator Annie Hoey. I welcome members of the Joint Sub-Committee on Mental Health to the meeting this morning to discuss the significant need for investment in mental health services and how to respond to the increased need for the service provision arising from the impacts of Covid-19. I welcome our witnesses, Ms Fiona Coyle, CEO, and Ms Bernadette Grogan, policy and advocacy co-ordinator, Mental Health Reform; and Dr. Fiona Keogh, director of policy and research, Mental Health Ireland.
Members now have the option of being physically present in the committee rooms or may join the meeting remotely from Leinster House. Members in attendance are asked to exercise personal responsibility in respect of themselves and others in terms of the risk of contracting Covid-19. They are strongly advised to engage in the practice of good hand hygiene and leave at least one vacant seat them and others attending. They should also maintain an appropriate level of social distancing during and after the meeting. Masks, preferably of medical grade, should be worn at all times during the meeting, except when speaking, and I ask for the members' full co-operation in this.
Before we hear our witnesses' opening statements, I need to point out to them that there is uncertainty that parliamentary privilege will apply to their evidence from a location outside of the parliamentary precincts of Leinster House. If, therefore, they are directed by me to cease giving evidence on a particular matter, they must respect that direction.
Ms Fiona Coyle:
Ba mhaith liom buíochas a ghlacadh leis an gCathaoirleach agus le baill an choiste as an gcuireadh teacht ina láthair inniu. Thank you, Chair, for inviting us here today. I am joined by Ms Bernadette Grogan, our policy and advocacy co-ordinator. Mental Health Reform is Ireland’s leading national coalition on mental health, with more than 75 member organisations working for progressive reform of mental health services and supports in Ireland. We welcome the opportunity to update members on the need for investment in mental health in the context of the increased need for services arising from Covid-19. There are three key areas regarding our mental health services that I would like to highlight this morning: resourcing, rebuilding and reforming.
Prior to the pandemic, mental health services in Ireland were already under pressure, with long waiting lists, staff shortages and a lack of therapeutic support in many areas. Investment has been long needed in primary care to improve access to psychology services, talk therapies, counselling, psychologists, social workers and social prescribing. Covid-19 laid bare the inadequacies of our mental health services. High quality services demand high levels of investment. As outlined in our pre-budget submission, the Government needs to increase spending on mental health to 10% of the total health budget. The World Health Organization recommends 12% while Sláintecare recommends 10%. The UK spends nearly 13% of its health budget on mental health. Currently, in Ireland, expenditure on mental health is approximately 5.1% of the total health budget.
Last week, before the Joint Sub-Committee on Mental Health, the Minister of State, Deputy Butler, said that this figure may not be fully reflective of the range of mental health supports which may be provided across other services and Departments. The figure was derived from available data and highlights our call for better data on mental health services and outcomes. For budget 2022, we are calling for an additional €85 million; €20 million to maintain existing levels of services and €65 million to be used exclusively for developing new services to drive change in the system and deal with the current challenges. The €10 million announced in February 2021 for mental health impacts of Covid-19 has not yet been spent. This funding must be ring-fenced and the proposed initiatives in place by the end of this year. All announcements in budget 2022 should be surplus to the €10 million.
Effective leadership will be key to driving rebuilding of mental health services. For that reason, we strongly believe that a dedicated lead for mental health needs to be created within the HSE. This lead should report directly to the CEO and drive forward the changes needed to realise the Sharing the Vision implementation plan. We need to build community mental health services to ensure needs are met. Due to Covid-19, many services provided by the community and voluntary sector moved online. The past 18 months have seen the growth of e-mental health initiatives and we call for these initiatives to be supported and expanded. Our Brave New Connections project is supporting capacity building for non-profit organisations, focusing on aspects of their activities and services where they have had to adapt or respond to the challenges of the pandemic.
However, we must equally be aware of the existence of a digital divide and that some of our most vulnerable and marginalised have been excluded from accessing online supports. While the additional €1.1 million in Covid-19 funding allocated to the sector was welcome, a significant digital divide remains. Mental health is not a matter for the health sector alone. Good mental health for the population of Ireland cannot be achieved without measures being taken by other Departments. We must reduce the risk factors for poor mental health in crucial areas such as income, employment and housing. Sharing the Vision includes recommendations for other Departments and we urge a collaborative approach to address all areas which affect mental health.
Mental Health Reform welcomed the publication of the heads of the Bill for the mental health (amendment) Bill. Ireland has an opportunity to introduce person-centred, progressive and non-coercive legislation, which is compliant with human rights and the UN Convention on the Rights of Persons with Disabilities, UNCRPD, and is adequately funded. We look forward to working with members during the legislative process. We believe that a draft Bill will be coming before committee imminently. We respectfully request confirmation of whether this joint Oireachtas committee or the sub-committee will undertake the pre-legislative scrutiny. We have an opportunity for the pre-legislative scrutiny to be as thorough as possible. We also have concerns around Part 5 of the emergency measures legislation. Mental Health Reform calls on the Government to review and repeal Part 5 of the Emergency Measures in the Public Interest (Covid-19) Act 2020 to strike a better balance between the need to protect people from Covid-19 and the protection of human rights.
Mental Health Reform looks forward to working with the committees, relevant Ministers and others to ensure that services are adequately resourced, are rebuilt and the legislation is reformed.
Dr. Fiona Keogh:
Mental Health Ireland would like to thank the committee for the invitation to participate in the meeting today.
We welcome the opportunity to discuss the significant need for investment in mental health and the need for support for people impacted by Covid-19. There was a huge mobilisation of mental health services and the entire health system in response to Covid-19 and great agility was shown in many aspects of the health service to respond to the unprecedented challenge. The unstinting work of all those involved is very much appreciated. In the midst of Covid, the new mental health policy was launched. Sharing the Vision set out to reframe our understanding of mental health and how we can respond to the full spectrum of mental health need through harnessing the wide range of resources in the community and the health system. It acknowledges the range of determinants of mental health from housing to employment to the physical environment and more and influences across the lifespan from infancy and early childhood experiences through to later life. As a leading organisation in mental health promotion, Mental Health Ireland is fully committed to playing a strong role in the implementation of Sharing the Vision.
Covid-19 provides an excellent analogy for understanding how we might respond to the spectrum of mental health need. We all became expert to some extent on a public health approach to a serious disease - how the most effective strategy was a population-wide approach to avoid getting the disease. It brought home to us all the power of small collective preventive actions in preventing serious illness and deaths - ultimately ensuring that Covid would not overwhelm our hospitals. The effectiveness of the public health approach has long been recognised and underpins Sláintecare - accessing care at the most appropriate and cost-effective service level with a strong emphasis on prevention. In a prescient way, the mental health policy Sharing the Vision emphasised the importance of prevention and mental health promotion - broadening the base of the mental health system so that people can easily access support at the primary care level and in their local community only escalating to a specialist mental health service when that is the level of support they require and not because it is the only source of support. A timely, appropriate response is essential to avoid potentially compounding mental health difficulties through long delays.
What does this mean in terms of our response to the mental health impact of Covid-19? It means that we should respond to need as it arises in different individuals and in different settings, for example, schools and workplaces. We know that the Covid-19 crisis has affected individuals' mental health in different ways resulting in loneliness, fear, trauma, unemployment, anxiety, increased alcohol consumption and increased domestic abuse. These effects require responses from a range of services and agencies. Specialist mental health services are an essential element of the response for some but certainly not for all individuals. The challenge in Ireland is that Covid-19 has landed on a mental health service that is already fragile and over-stretched. Broader-based services in primary care settings and the community and voluntary sector all have an essential role to play. However, resources for mental health have almost exclusively been directed towards specialist psychiatric services to the neglect of primary care mental health services. Mental health promotion and building resilience, which we now know constitute the cornerstone of a public health approach, have not been seen as the core business of either mental health services or health promotion services and have not been resourced accordingly. It is important to say that the choice here is not between specialist mental health services or non-specialist services. Just as mental health needs exist along a continuum the response to this need requires a continuum of services. I will not revisit the requirements here, which are set out in detail in Mental Health Reform's pre-budget submission, but investment is needed to maintain existing levels of service as well as to develop the continuum of services recommended in Sharing the Vision. New capital investment is needed to build new acute mental health units. Some essential elements of the system have never been built, for example, psychiatric intensive care units to enable safe and effective care to be provided for individuals with a high level of complex need. In Ireland, we often depend upon the Prison Service to respond to acute need. Opportunities can be maximised in other capital projects, such as in primary care centres, to co-locate mental health services, which facilitates the provision of integrated care.
In terms of the Government or State role in supporting mental health, where does responsibility lie? Of course, the Department of Health and the HSE have a central responsibility but the Covid experience has demonstrated how an effective public health response requires many Departments and agencies to contribute to a societal and economic recovery as well as recovery in individual health. The same is true for mental health. We know many factors have a role in determining and influencing a person's mental health and we need to become much better at working together. There are some examples to build on such as the joint policy statement on housing options for older people and the make work pay initiative of the Department of Social Protection. Over the past year, Mental Health Ireland employed 80 people with lived experience of mental health difficulties but more needs to be done for people with mental health difficulties who have fluctuating conditions so that there is a flexible approach to supports increasing and decreasing as a person's needs change. Modern and sophisticated social protection systems need to better accommodate this reality in people’s lives.
Looking positively to the future, we can use the opportunity provided by Covid to build a mental health support system that Irish people can be proud of. What might this look like? It would be an equitable mental health support system with access based on need and not ability to pay with an equitable distribution of resources across the country. It would be a co-produced mental health system that actively involves people with lived experience, families and supporters in the design, delivery and evaluation of mental health services. Crucially, it would be a broader-based mental health system with resources allocated to build existing services as well as developing a full continuum of supports. It would be an agile and innovative mental health system building on the use of e-mental health supports, which played such a crucial role during the pandemic, while recognising that these are just a tool and not a substitute for face-to-face interaction. It would be a mental health system that provides good value for money with long-standing existing services subject to the same scrutiny as new initiatives and with the confidence to decommission services that are no longer fit for purpose. It would be an outcome-focused mental health system with multi-annual budgets directed towards achieving the outcomes of Sharing the Vision and using funding mechanisms to incentivise integrated cross-Department and cross-agency working. It would be an implementation-focused mental health system. One of the reasons implementation does not happen in this country is that the implementation process itself is not resourced. It would be a system with a credible workforce plan that includes retooling and refreshing the skills amongst the existing workforce, which has shown its commitment to the sector.
We know from our experience with Covid that we can do this. When faced with a big enough challenge, the individuals and systems involved rose to the challenge and overcame it. We need to bring the same energy, resources and effort to improving mental health for all. Mental Health Ireland is hopeful for a better future. We must now decide to grasp this opportunity.
I thank members of the Joint Sub-Committee on Mental Health for attending this meeting, some of whom are attending for the first time. On behalf of the committee, I thank them for all the work they have done during these difficult times.
I thank our witnesses for attending and for their work and advocacy on mental health services. If Covid has taught us anything, it has shown us the importance of family, community and interacting with people so it is no surprise that this pandemic and the restrictions it has imposed have caused mental health issues in people. The witnesses would not be unique, and I think they would appreciate this, in advocating for extra money at this time of the year. I acknowledge that it is very merited. Ms Coyle mentioned an additional €20 million to maintain existing services. What would that be directed towards?
In terms of the model of service outside of the traditional nine-to-five, five-day-a-week service, how do the witnesses see emergency and weekend services and the need in rural communities? Where would the additional funding they are seeking to improve those services, particularly in rural areas, which I think they would appreciate are more difficult to provide for in terms of services outside traditional nine-to-five services, be directed?
Ms Fiona Coyle:
I can answer the Senator's questions. On the €20 million for the existing levels of service, as the Senator can appreciate, costs rise year on year. For example, the cost of running a service today will increase next year due to staffing costs increasing or basic costs like rent or electricity. That is the minimum that is required to run the exact same level of services that we are providing today, next year. What has happened in the past is that perhaps not enough money has been ring-fenced to provide for existing levels of service and new development money has been used to fill that gap. The new development money is important for putting in place new services.
The Senator made a good point in relation to the services being provided in rural areas. I am from Gortahork in north-west County Donegal, a very rural and isolated area. Therefore, I can very much appreciate how difficult it is to ensure that services are in place across the country. As many members will be aware, currently our services operate from 9 a.m. to 5 p.m. A mental health crisis does not happen between the hours of 9 a.m. and 5 p.m. It can happen at any time, and in particular, perhaps during the night-time hours. In our submission, we are asking for investment to be put into rolling out 24-7 services across the country.
Dr. Fiona Keogh:
I wish to add that e-mental health has a particular role to play in making mental health services more accessible for people, particularly those in rural areas. It highlights the need for the joined-up action that is required. For example, people need good and reliable broadband to do that. It is an additional tool that makes that initial contact more accessible. It is not a replacement for face-to-face contact. There is definitely a need for investment in 24-7 solutions.
Mental Health Ireland is partnering with the HSE in Galway, piloting a community café that runs 24-7. It has been located very close to the hospital there to provide that kind of support. It is a peer-led support model. I think we need to be much more imaginative in the kind of solutions that we develop, particularly for isolated rural communities.
I thank the witnesses for their replies. I know the former Minister of State, Jim Daly, put in place a one-stop-shop, as it were, in terms of accessing of services. There was a myriad of phone numbers that could be used as a first port of call to access mental health services. For example, the Samaritans provide an excellent service in Galway. How important are those services in terms of being the first port of call for someone in distress, whether it is in the middle of the night or after a night out, when they perhaps have drink and drugs in their system? How important are those initial phone calls and freephone numbers?
Ms Fiona Coyle:
Mental Health Reform is a coalition and many of our members - the Senator mentioned the Samaritans and others - provide those services. However, the main point of contact for someone with a mental health difficulty still remains the GP. That is why investment in primary care is so important. Currently, if someone goes to his or her GP, he or she is referred to a waiting list. Some people are waiting more than a year. A year is a long time when you are waiting for support. Different initiatives are needed, but that investment in primary care would be something we would emphasise.
I thank the witnesses for their insight. I know that we have limited time. I could spend the whole meeting talking about the issues around mental health, but I will limit what I say.
In response to Ms Coyle's question on the heads of Bill which will be coming to the committee for pre-legislative scrutiny, it is my understanding, and I stand to be corrected, they will be coming to this committee as the Joint Oireachtas Committee on Health.
There is an issue that I wish to touch on that I was prevented from speaking on in the past. It concerns Part 5 of the Emergency Measures in the Public Interest (Covid-19) Act 2020, amending the Mental Health Act 2001, that was mentioned by Ms Coyle. I agree 100% with the witnesses that it needs to be reviewed and repealed. As the witnesses will be aware, I tabled amendments earlier this year and I did not even get the chance to debate them because of the Government's undemocratic use of the guillotine procedure. I was effectively gagged, but I am using my opportunity to speak on it today.
As the witnesses will be aware, Part 5 of the Act provides for amendments to the Mental Health Act which allows mental health tribunals to be reduced to one-member, paper-based tribunals with minimal personal interaction between the relevant persons. This legislation was introduced originally to reduce the amount of personal interaction between the relevant persons to prevent the spread of Covid-19. It was first introduced in the context of an emergency. However, we have moved on since then. It is my understanding that there have been almost 800 mental health tribunals since the emergency powers were introduced and these powers have not been used once. I stand to be corrected on that. Perhaps the witnesses have more information on that, but it is my understanding that the powers have not been used once. In my opinion, there is no need for these emergency powers if all the evidence suggests that they are not being used. We need to protect people's human rights. It is as simple as that. I ask Ms Coyle to outline briefly for the committee the concerns she has if Part 5 of the Act is not repealed.
Ms Fiona Coyle:
As I said, the emergency legislation was implemented during a unique time in this country, but as it currently stands, it is not compliant with international human rights law. From the data made available by the Mental Health Commission, some parts of the Act have not been used. Our view is that if the powers have not been used, there is no need for the Act to be there in its current form because it leaves the door open to people not getting access to the type of tribunals that they have the right to access. We have been urging the Government for the last number of months to repeal Part 5 to ensure that our legislation is as human rights-compliant as it can be.
I appreciate Ms Coyle's response. I have limited time so I will move on. We have all seen the impact that Covid has had on mental health services. However, we were in a mental health crisis pre-Covid. There is no getting away from that fact. We are now in a mental health emergency. We have heard the Government announcements over the last while in relation to one-off funding for mental health. As Ms Coyle said, the €10 million in funding that was announced in February has not even been spent yet. I accused the Government at the time, and I will stand over what I said, of making the announcement for cheap headlines when the money was not going to the people that I deal with on a daily basis who are providing front-line emergency mental health supports to our communities. I am not even talking about some of the more traditional mental health supports. Dr. Keogh stated that a holistic approach is required. I am not just referring to the traditional front-line mental health supports. Those working in family resource centres, youth services and direct provision centres are all on the front line of this mental health crisis and emergency. People are banging down their doors seeking to access the care they need, when and where they need it. The big issue we have is ensuring that we get the appropriate care to people where and when they need it.
I ask Dr. Keogh to outline briefly the benefits of multi-annual funding over one-off piecemeal funding. It is important.
Dr. Fiona Keogh:
It is a huge challenge for organisations in the community and voluntary sector, in particular, that they are continually looking for a budget every year. They have no certainty of funding in terms of planning and developing services. We know that these organisations are a crucial part of that continuum of support to avoid people being unnecessarily forced up to the most specialist level of the system, when in fact the support would be more appropriately provided wherever they are living, in their own homes, or other settings like workplaces, schools and so on.
Multi-annual funding for community and voluntary organisations is an important commitment. That needs to be tied to those organisations working to meet the outcomes that are set out in Sharing the Vision. Many of them already do that but we could be better at setting out that we will give them annual funding to do this, this and this.
Another important thing that could be done within the front-line mental health system is to maybe be more imaginative and flexible in who is being recruited. There are shortages in certain staff groups or certain specialties and rather than continually going to the marketplace, knowing that we will not be able to recruit from certain groups, if we look more specifically at need within a team or within a local area and maybe recruit to fill specific needs such as family therapists and people who have specific psychotherapeutic skills, who would obviously be appropriately trained, accredited, registered, etc., that would go some way to addressing some of those gaps. While the workforce is built, that is another parallel piece of work that needs to go on.
Ms Ber Grogan:
I am really nervous. This is my first time on this side. Some of the members know me from being a parliamentary assistant in the Houses since 2014 but it is a very different experience this morning.
I just wanted to jump in on this point. Obviously, it was welcome that €1.1 million was made available to the community and voluntary sector to move to online spaces due to Covid. As Dr. Keogh said, it does not replace face-to-face. As part of Mental Health Reform, we are undertaking a project called Brave New Connections and part one of it was launched recently with survey results. That was basically a survey of our members about how they were working in Covid times and how it was for them working online. Some 80% of the respondents said that they work directly with service users while 95% of them expanded their services to online options. Some 70% of them said that they had difficulties but one of the main difficulties was on the service user side - people having access to laptops, tablets, mobile phones. Of those surveyed, 65.5% said that they had technical issues. Again, it is that whole joined-up thinking in terms of providing the funding but will the people who need the supports be able to access it?
At last week's Joint Sub-Committee on Mental Health, Senator Dolan mentioned the libraries and the education and training boards, etc. Again, it is that cross-governmental cross-Department attitude towards access.
On the €10 million Deputy Mark Ward talked about, and it is great to see him healthy and back again after his fight with Covid, Deputy Róisín Shortall recently asked some parliamentary questions on our behalf, trying to find out what initiatives were in place. The Minister said that they were still looking at initiatives and they wanted to see what the priority areas were. That is all great but, as the committee will be aware, it is the community and voluntary sector organisations on the ground which are dealing with this daily and they deal with vulnerable people and people in need to whom you cannot say to wait until the end of quarter 4 2021 and then you will get back to them. That is why multi-annual funding is important. It allows important services to be able to plan, and also contingency plan. We were moving towards e-mental health, but none of us could have expected this.
Sorry, I have probably gone over time but I just wanted to jump in there.
Thanks, Chair. I will start with Ms Coyle. In her presentation, she referred to the three Rs - rebuilding, reforming and resourcing. I ask her to speak for a couple of minutes on the reforming side. What are the priorities in terms of how services should be reformed?
Ms Fiona Coyle:
There are two aspects to the reforming. I will speak to one and pass over the other to my colleague, Ms Grogan. We have already spoken about the need for a cross-governmental approach so that we break down this notion that mental health is for the Department of Health alone. We need to look more broadly at it and we need to have meaningful engagement and commitment as well as money and investment from other Departments. Quite often what has happened is that a Department would be willing but when it would come to putting money on the table, it would look to see whether the Department of Health provided the funding there. That is something that has to change. The Sharing the Vision document outlines very well that necessary reform of moving to a system where service users have such a say in their mental health journey. Everyone who accesses mental health services may need a different service, everyone's journey is unique and we need a service that has those doors for people to open. There is a lot there. On the reform of the Act, maybe I can pass over to Ms Grogan to quickly make one or two points in relation to what needs to reform in that regard.
Ms Ber Grogan:
I am obviously new with Mental Health Reform. This is week six and I hope I am doing it justice with the bits and pieces that I am talking about.
One of the things I am working on is looking at the heads of the Bill to amend of the Mental Health Act 2001. Obviously, it is a long-awaited amendment of the Mental Health Act to bring it into compliance with the Convention on the Rights of Persons with Disabilities, UNCRPD, which we ratified in 2018, and with human rights law. It has been functioning outside of human rights legislation for a long time.
The heads of the Bill are interesting, but I suppose one of the things we were looking at is that the 2015 expert group's 165 recommendations were brought forward prior to the ratification of the UNCRPD. We can speak about things being person-centred, individual care plans and listening to the person but there has to be a whole culture change in moving away from the biomedical models and looking at people. There is a huge opportunity now for the Oireachtas with the amendment Bill. We had the Assisted Decision-Making (Capacity) Act in 2015. Not all of that has been commenced. There was the Mental Health (Amendment) Act 2018 on the definition of "voluntary patients". That has not been commenced either. When we talk about reforming, we mean putting it into action.
Sure, and thanks for that. We talk a lot about the need for early intervention. Dr. Keogh or Ms Coyle might be able to respond on this. Is anything happening, or are there proposals for any programmes, within schools to improve children's well-being and build their resilience in terms of responding to challenges that they meet, and particularly in disadvantaged areas, in order to protect their well-being and mental health, and specifically to assist them in withstanding difficulties that arise in their lives?
Dr. Fiona Keogh:
My understanding is there is a schools well-being programme being implemented at the moment. This is very much focused on just that - on building resilience and on giving children the life skills they need to be able to cope with the bumps and knocks of life.
Plenty of research evidence tells us that this kind of programme and intervention is a good investment. There is a $1 to $8 return on these kinds of programme.
Ms Ber Grogan:
I know from last week's meeting of the Joint Sub-Committee on Mental Health that the Minister of State, Deputy Butler, was going to have a meeting with the Minister for Education, Deputy Foley, that afternoon because the sub-committee's members had highlighted the need for cross-governmental work. I do not know whether there has been an update since.
I thank Ms Grogan.
I will move on to the issue of 24-7 services. We have been hearing about the need for them for a long time. Have there been improvements, particularly in emergency departments where people can turn up in serious distress? Rather than being sent home from emergency departments, are there now referral pathways in many of our acute hospitals? Is progress being made on that front?
Ms Fiona Coyle:
I am happy to take that question, and Dr. Keogh may be able to add something. I believe there are pathways in place. As part of our pre-budget submission, we heard from more than 300 individuals, and a matter that was often raised was their experience in accessing mental health services through emergency departments. Their experiences varied, as has the level of progress, and we do not have evidence or research to show the impact of that progress. What we know is based on anecdotal evidence at the current time. There are efforts being made to improve pathways, but we do not know whether people's experiences and outcomes are improving.
Ms Ber Grogan:
I believe the cyberattack had an affect on that as well. In our My Voice Matters survey report in 2019, 49.3% of respondents stated that they had not got the support they needed when they attended an emergency department about their mental health. That was before Covid, after which emergency departments became even more stretched.
Dr. Fiona Keogh:
It would look different. It would involve a different kind of interaction from the outset after someone got in touch with a mental health service and would entail establishing what the issue was for the person. Sometimes, there can be a response that does not take full account of the person's life experience and what has brought him or her to that point and is instead just about fixing the presenting problem. Sometimes, a little more time and engagement are needed. The model would involve listening to and engaging with the person and identifying what his or her priorities are instead of moving too quickly to determining how to fix the presenting problem. A great deal of work has been done on this model.
I am trying to remember the actual term for it, but a dialogue programme that has been running in west Cork involves a system of assessing and working with individuals and their families that has been successful in Finland. I believe it is called Open Dialogue. It is completely different. A team comes together, the person and his or her family members are there if that is what he or she wants, and they work together to establish what the issues are and how they can be resolved. Care planning is a part of that approach. The care planning process can sometimes be seen as overly bureaucratic, but if it is done well and properly, a care plan is a jointly produced programme wherein the mental health professionals, the person and his or her family have to work together. It cannot just be about prescribing something and telling the person to do what he or she is told. Rather, it has to be a more interactive process.
My second question will be general. Last week, I mentioned the mental health budget. Ireland spends just over 5% of its overall health budget on mental healthcare. According to Sláintecare, other European countries and the UN, we should be spending between 10% and 14%. Even Britain spends 13% on mental healthcare in the NHS. In the opinion of Mental Health Ireland and Mental Health Reform, how do we close that massive gap? If there is no political will to close it, we could still be talking about it in ten years' time. If someone in a mental health crisis receives an intervention at the right time, the outcome is very good. If people do not get mental healthcare at that time, the outcomes are dire. How do we close the gap in budgetary spend on mental healthcare?
Ms Fiona Coyle:
As I said in my opening statement, high-quality services require high-quality investment. That is the fact of the matter. In Ireland, we have a history of underinvestment in our mental health services, so we are starting from a low base. We need to have a plan in place. Through Sláintecare, the Government has committed to spending 10% of the health budget on mental health, but how will we get from where we are to there? That is the question we would like answered.
Money alone is not the solution. It will not achieve the reform that is needed. We need political will and leadership. That is one of the reasons we have been calling for a very senior role within the HSE at director level or above. Key to the role is that its holder would report directly to the CEO of the HSE, drive the reform that is required and provide leadership and strategic direction. If we are serious about giving mental health parity of esteem with physical health, investment and leadership are both necessary if we are to promote and provide better services for individuals across the country.
Dr. Fiona Keogh:
I might just add to that. If we have a ten-year costed implementation plan for Sharing the Vision, it does not mean that we have to jump from 5% to 10% by next year. Over a ten-year period, we should be able to move to at least 10% incrementally.
If we are calling for much better cross-governmental, cross-departmental and cross-agency working, we should also get better at tracking the contribution that is being made by other Departments and agencies to mental health spending.
For example, if the Department of Social Protection is funding employment support workers, that is a crucial part of the mental health infrastructure. If the Department of Housing, Local Government and Heritage is funding housing support workers, again, that is crucial, as it is if the Department of Education is funding psychological supports in schools. We need to be much better at capturing that. It should not be beyond our collective wisdom and effort to be able to move incrementally to 10% over a ten-year period.
Again, I have a quite general, nuanced question. Does Dr. Keogh have confidence in the Sharing the Vision policy document? The precursor to it, if you look at it, was largely never implemented. We all know documents can be filed away and there are never any actions. Does she have confidence in the Sharing the Vision document?
Dr. Fiona Keogh:
I have confidence in the document. I should declare a conflict of interest because I was a member of the oversight group that developed the policy. I was also the researcher working with the expert group that wrote much of A Vision for Change. I disagree somewhat with the Deputy on the implementation of A Vision for Change. Everything in it was not implemented and there is still a long way to go on staffing levels, but it brought about important changes in the mental health system and it set out the infrastructure we are now working towards. Implementation has been painfully slow, unfortunately.
The implementation structures in Sharing the Vision have been much more sophisticated from the outset, which was one of the difficulties with A Vision for Change. There is a very well-worked implementation group with a number of panels working to it. We have learned much more about how to go about implementation. In recent years, the mental health directorate in the HSE has adopted a very interesting approach to resourcing implementation. That was one of the points I made in my opening statement. We can sometimes think implementation is a magic process and if we really want to implement Sharing the Vision it will somehow happen, but we need to resource that process. It involves change and we all know that change, for structures and individuals, is difficult. We have to learn new things and change how we might have done things in the past. I have confidence the implementation structure is good. We need to support it with a critical eye and keep encouraging it, but also critically moving it forward.
I will ask about the staffing issue and the challenges we currently have in relation to it. In some areas we are having difficulty getting psychiatrists and doctors, but have we a sufficient number of places for the training of people in, say, psychiatric nursing and related areas? Are we producing enough graduates in those areas if we are to plan for the future? In particular, we need to look at the number of people retiring from the service, whether they are doctors, nurses, care assistants or staff on the administration side. Has any analysis been done on the challenges we will face on that over the next five years?
Ms Fiona Coyle:
I am happy to speak very briefly on this. Staffing continues to be one of the biggest challenges our healthcare system faces and within that our mental health care services. The HSE has a workforce plan in place but we know that across the country community mental health teams are not fully staffed and are not at full capacity. There are difficulties in recruiting within specific disciplines. Efforts have been made in recent times. The HSE has invested in the training of psychiatric nurses and that is coming to fruition now. Again, we are looking cross-departmentally on the need for the Department to hire those in education to support, to get involved and to ensure the numbers will be there into the future. It requires a lot of co-ordination.
Is there any evidence that co-ordination is occurring? It is fine to say we need more staff, but have we any evidence of direct communication from educators and people producing the graduates, whether it is through Further Education and Training Awards Council, FETAC, 5 or FETAC 6 courses for care assistants, etc., or engagement on what the service needs? One of the areas I am working on is home care. I not satisfied we have a sufficient number of training places for people who want to provide home care. Likewise, I am not convinced we have enough training places for people who want to go into the area of psychiatry and giving back-up support. What can we, as a committee, do about that particular aspect?
Ms Fiona Coyle:
Yes. This is an area that can be strengthened. There is minimum engagement currently but, again, the HSE is best-placed to give concrete answers. The committee can encourage that discussion. Resourcing for courses should not be coming from the HSE budget; it should be coming from the higher education budget. There have been incidences where that has not happened and there is a role for this committee in that.
The other issue I will raise is that of people who wanted to do nursing or psychiatric nursing but, for one reason or another, did not get into it and are still working in the health service. Is there adequate provision for them to go back to education without having a huge loss of income? Can we have a level of engagement with them to encourage them to move up along the line in relation to services they are providing?
The other issue I want to raise relates to rural areas. We have had a number of very serious incidents in the south and south-west regions, where there have been a number of tragedies. Has anything additional been done regarding public health nurses, or anyone working in mental health services and people working in the community, especially in rural areas, in order to deal with the new challenges? I am not denying there is a problem in urban areas but there is a particular issue with isolation in rural areas. Is there any evidence of additional effort being made to give support to people in those areas?
Ms Fiona Coyle:
One of the issues we previously raised related to redeployment during the Covid-19 pandemic. We are aware there have been some redeployments of psychiatric nurses and community nurses but we are unable to get precise figures from the HSE in that regard. It is very important to take into consideration how redeployment has impacted services. In addition, many of those community mental health teams across the country are not at full staff capacity. That impacts on the quality of service they can provide and on the waiting lists for people who are accessing those services, especially in rural areas where it may be more difficult to recruit staff. Those challenges exist.
I will ask about the different areas within the HSE. I am in the south-south-west area. Is there a major variation between services available depending on the area you are living in? Is there an urgency and a far greater need to upscale the level of support being provided compared to what is being provided at the moment?
Are the witnesses concerned about particular areas? I know they are concerned about the whole area but in particular, are there-----
Ms Fiona Coyle:
We are national but I often say it is an Eircode lottery in Ireland. There are areas where there are services and there are areas where there are none. There is no equitable access across the country. We could not provide the Deputy with details here on which areas lack particular services but we know it is a lottery in terms of what services are available and how long it will take someone to access them.
Ms Ber Grogan:
To bring it back to the cyber attack, I looked at the parliamentary questions asked just before the summer recess and found that 106 mentioned mental health. Obviously, I did not count them. The information is provided on the Oireachtas website. It seems that it was not possible to answer most of them so there is a significant dearth of information there. Obviously, we are not linking in in that way with the HSE but, again, in respect of our Brave New Connections project that involved looking at our members, 58 out of the 77 members completed the survey. More than 90% of them said that Covid had meant more emphasis on supporting the staff. Mental Health Reform did a piece with the National Women's Council because women are disproportionately represented in front-line work so there is that gender aspect. We have seen that community and voluntary services are putting things in place such as employee assistance programmes, supervision and attempts to support their staff in terms of mental health, so we hope this is echoed in the front line.
Regarding the training of the nurses and staff we need, looking at Sharing the Vision and the services to which we wish to move, we are talking about occupational therapists and speech and language therapy so we must again join the dots in respect of the type of mental health services we want. We are talking about tenancy sustainment officers in housing. This is one of the reasons I have requested meetings with many different Ministers not just the Minister for Health or the Minister of State, Deputy Butler. We have been reaching out this year to Ministers and Members across the board to talk about that cross-Government need for investment in mental health and not just leaving it all to the Minister of State with responsibility for mental health.
Dr. Fiona Keogh:
In respect of Deputy Colm Burke's question on geographic areas, we know there are geographic inequities in accessing services across Ireland. While rural areas have specific challenges, much of the time, the gaps are in urban areas because of the disproportionate increase in population and the disproportionate spread of development in the country.
Speaking to Deputy Gino Kenny's question on how we move forward in terms of increasing funding, as we increase the funding for the mental health system incrementally, one way of doing that would be to tag it to levelling up so we target those areas where the gaps are and the geographic inequities lie and direct funding in that way. This means that every year, every area will not get the same because we need to own that and take a mature approach to addressing those inequities.
I thank the witnesses for their fantastic presentations. It is wonderful to hear them speak. I have so many questions and I hope I can get them in on time. The witnesses spoke about cross-departmental engagement. As chair of the Joint Sub-Committee on Mental Health, I see a huge need for that cross-departmental approach to mental health and to address the factors relating to mental health and the role social injustice and inequality play in this. We need to work with the whole system to improve health and well-being. In what ways can we strengthen our cross-departmental response or do the witnesses feel there is a lack thereof? I want to find out more about this because it is very important.
Ms Ber Grogan:
One of the things I was looking at this week was the first report on the well-being framework for Ireland. Obviously, at budget time, we talk about equality budgeting and that theoretically we are looking at inequalities. The Parliamentary Budget Office, PBO, produced a commentary on the well-being framework and said that in the well-being framework with the indicators, the role of the Oireachtas is not currently outlined. The PBO suggests that an Oireachtas committee with a cross-cutting focus should provide overarching parliamentary oversight of the framework. Everything we said today is echoing this cross-governmental approach. There is no health without mental health. All aspects of everything affect our mental health. If we are talking about introducing this well-being framework, and moving in that direction around budgeting and looking at outcomes, this is a really great opportunity to start that.
Dr. Fiona Keogh:
If we think about how we facilitate cross-departmental working, one of the things I learned about the implementation, or lack thereof, of A Vision for Change was that the Civil Service, the Department and the Oireachtas need structures to enable this to happen. It was probably a bit naive of me but I have realised that Secretaries General and assistant secretaries need these formal structures so that they can communicate. Joint funding is another way to really incentivise it. A joint funding package is put forward in respect to housing and mental health, social protection and mental health or justice and mental health and it is seen as a win-win rather than Departments having to compete and fight with each other. This is a win-win for everybody, but most importantly the people who need the supports. The First 5 strategy for young children and families is a really good example. If we can get that early intervention, we know it is such a worthwhile investment. It is that approach to very long-term, slow and incremental gains. Nobody will be able to see big things it can point to within a political term and say "we did that" but in ten, 15 or 20 years' time, we should be seeing gains across society in terms of lower levels of criminality and so on if we can get in early and really support children and families. Joint funding would be a really good way of doing that.
The witnesses mentioned that the €10 million announced in February to deal with the mental health impact of Covid-19 has not been spent. This funding must be ring-fenced and proposed initiatives must be in place by the end of the year. Could the witnesses give us an update on this and tell us their thoughts on it?
Ms Ber Grogan:
I have the replies to parliamentary questions from Deputy Shortall. There has been no update since last week. I know it was raised during a meeting of the Joint Sub-Committee on Mental Health. The only update we have is that initiatives are being decided on, priorities are being looked at and it is hoped they will be in place by the end of quarter 4. The Senator knows it relates to delays. We do not even have any idea of what priority areas would be. There has been much talk today about rural areas, accessing people and creating the spaces for access so we will just have to wait and see what the Department and the HSE decide. However, we want it to be separate from whatever is in the mental health envelope in budget 2022.
I am flying through my questions because I want to get through as many of them as I can. The witnesses said effective leadership would be key to driving the rebuilding of mental health services and that for that reason, they strongly believed that a dedicated lead for mental health needed to be created within the HSE. The HSE appeared before the Joint Sub-Committee on Mental Health yesterday to discuss the closure of the Owenacurra Centre in Cork, which is a wonderful service.
Can one of the representatives from Mental Health Reform elaborate on what it envisages in the context of this lead person? What is its thinking is on that?
Ms Fiona Coyle:
I am happy to take that question and I thank the Senator for it. The position of director of mental health services was in place previously but it was lost a number of years ago. There is broad agreement on the importance of having a senior decision-making strategic role in the HSE. That person needs to be report directly to the CEO. Many structural barriers need to be addressed and there is a need for that senior level of leadership to bring about that change. We are calling for that position to stated immediately. Again, it speaks to HSE taking seriously the issue of parity of esteem between mental and physical health.
I thank Ms Coyle for that response. I direct my next question to Dr. Keogh. Apart from capital investment, what in her opinion is the biggest obstacle in our public health approach? She mentioned in her opening statement that "... resources for mental health have almost exclusively been directed towards specialist psychiatric services to the neglect of primary care mental health services". Does she think that is hindering equitable access to mental health primary care?
Dr. Fiona Keogh:
It very much is. Mental health promotion, for example, can be described as the orphan child of the orphan child if mental health is the orphan child in the sense that it is not seen as the core business of a mental health service. It probably is not; it sits better in a wider community approach.
In terms of access to primary care mental health supports, the counselling in primary care service was put in place and funded by the mental health service as a proof of concept to be taken up by primary care and expanded and funded. It speaks to that discussion as to whether the mental health budget should be funding primary care services. It has a mental health label attached to it but certainly funding is needed to expand counselling in primary care. We know it has worked. Waiting lists have already developed because of the popularity, usefulness and benefits of that service. The evaluation of that service was very positive with 70% to 80% of people seeing significant reductions in their symptoms or presenting issues. That is definitely a high priority.
I will keep it short. I want to ask one of the representatives from Mental Health Reform about an issue we touched on in the sub-committee meeting last week. How does Mental Health Reform engage the views of service users, of people with lived experiences, in its work? This is such an important issue as we move forward. We need to hear more from the service users. Can one of the representatives advise us on that?
Ms Fiona Coyle:
Yes. For Mental Health Reform and, I am sure Dr. Keogh would agree, for Mental Health Ireland, the voice of service users is key to what we do. Mental Health Reform has a grassroots forum comprising service users, their families, friends and carers with whom we engage on policy positions. We also frequently engage openly with the general public. Our pre-budget submission has been informed by more than 300 individual submissions by service users and their families and carers. It is important to thank them for that. The detail and richness of the responses we received are very enriching. The Senator will note the quotes in the submission. We have sent in a budget submission and the quotes are probably the most powerful part of it. We also mentioned My Voice Matters survey, the first of its kind in Ireland, in which service users were asked for their thoughts on the types and quality of services they were receiving, and we sent that on. That was done in 2019. We try to ensure service users are at the heart of everything we do and our members assist us in that process. Mental Health Ireland has great knowledge and experience of co-production in what it does.
I thank and compliment our witnesses on their addresses to the committee. It is high time not only the members of this committee but all those working in the general health services focus on this issue. How many minutes do I have? It must be very few at this stage.
I could do a lot of damage in six minutes. I will set into it. I must agree entirely with the comments of our witnesses on the general availability of mental health services at present. As Deputies, we all deal with many cases of parents with children who have mental health problems and attempting to gain access for treatment in a hospital or sometimes even to an accident and emergency department is nearly impossible. There seems to be a lack of awareness of the seriousness of the problem as it affects mental health patients. There does not seem to be an alertness to the fact that if the issue is not dealt with in the early days it can get dramatically worse in a very short time. That also applies to adult patients. We have all dealt with, and continue to deal with, cases, for example, where a patient is not co-operative, is suicidal and does not want to be helped in any way but a way must be found to encourage the patient and to deal with the situation. A patient cannot be allowed to float in the wilderness with no assistance, no place to go and nobody to reach out to.
The number of cases where a patient is discharged prematurely, sometimes in the middle of the night, with no place to go, is alarming and appalling. That practice did not start recently. It started about 20 years ago.
The decongregation of mental hospitals was never probably planned, funded or implemented. It still is not. As long as it goes on, we will have major deficiencies. We will have breakdowns in the system. For example, a situation occurred not so long ago where a juvenile patient, who was severely affected, injured himself to the extent that he needed hospital treatment. He was brought to an accident and emergency department and waited all day and all night there. What in God’s name has gone wrong with the system? The parents and the families are very frustrated. Only for the families that follow up and the mothers, fathers or family members who stay in hospitals overnight continuously to insist on treatment for their child or sibling, the whole system would break down.
There is a necessity to identify the basics that have to be put in place as a matter of urgency. Whatever it takes to fund that, we have to do it. We are obliged as a society to respond to the health and all the other needs of our society, but we need to deal with this issue as a matter of urgency. We have all dealt with extreme cases where we believe something should have been done and ask why it was not done and who is to blame. The blame game is no good to patients who have injured or harmed themselves. The necessary service needs to be put in place. Whatever funding that requires must go with it. If we do not do it now, it will get dramatically worse. It impacts on all of us if we do not take the necessary action.
I do not want to go on about it. Most of what I want to say I have said many times previously. I know what the witnesses are saying. They will get a good hearing here. I am not saying anything by way of criticism. This is a fundamental issue and the Department of Health and all involved must examine the seriousness of the situation and deal with it as a matter of urgency.
Ms Ber Grogan:
I will. I thank the Deputy for his comments. I was delighted to see him still in his summer suit the other day in the Chamber. His point is excellent and it is why we have been calling for a national advocacy service for young people and adults in mental health services.
As the Deputy so rightly stated, there are parents who will stay in the accident and emergency units and who are constantly advocating for people. That is great for people who have supports. What about the people who do not have anyone to advocate for them? Perhaps their supports are in services which are provided by some of our member organisations. It is heartening to see that advocates are mentioned in the new heads of the Bill but this is talking about individuals. I would be interested to see if we will be drilling down more into that to say that this could be a support organisation because not everyone has an individual to advocate for them, particularly if one has enduring mental health issues. A national advocacy service is something that Mental Health Reform has been pushing for for a considerable period of time.
On the point of parents advocating for their children, I wanted to inform the committee that the Huntington's Disease Association of Ireland is one of our members. It got in touch with us today to tell us about a child in Mayo who has Huntington’s disease, who will be waiting two years to access the child and adolescent mental health services, CAMHS, and who has acute anxiety. We were talking earlier about the Eircode lottery but this is completely unacceptable. We know that there are more than 2,700 children are on waiting lists for CAMHS, with hundreds waiting more than a year. This is very dangerous. An advocacy service would help that, together with an independent complaints mechanism which does not exist at the moment.
My apologies, Chairman, as I was trying to multitask.
I thank all of the witnesses. I will make a number of brief points. There is a similarity between both organisations presenting to the committee today. I believe Dr. Keogh referred to care being based on needs rather than on the ability to pay, which is spot on. This can be a very significant barrier. It is tough enough to get any assistance when it comes to mental health but if one has the cash one has some chance of getting one’s foot in the door. I know from being on the Sláintecare committee and on the Committee on Future of Mental Health Care, that we always reiterated that point.
Touching on the community and voluntary sector, which is a vital cog in the service, the professional side of the HSE and recruitment has been a very significant issue. Our witnesses are correct in referring to the need to think outside of the box in that if one cannot get a specific professional, one should get the next best person, which is better than not getting anybody. We had discussions yesterday on another committee on retention. One particular post was advertised for 13 years and was never filled, which was crazy.
Our witnesses mentioned schools and funding. I see that back in 2020, €2 million was proposed for third level education and for extra help in some universities because of anxiety and mental health issues. That was not spent either. A great deal of money has been promised but is not going to where it should be.
Ms Grogan mentioned the Assisted Decision Making (Capacity) Act and other Acts such as the Mental Health Act. They have been very slow and without progressing those as fast and as hard as we can, we are not going to achieve what our guest speakers have sought to achieve, which is a proper functioning mental health service within the country.
I refer to the Midleton Centre for Autism funded by the Department of Education, which is the only all-Ireland specialist autism centre. With Brexit and discussions on a united Ireland coming down the tracks, is there any way we can give this issue an all-Ireland dimension? We are an island and we can learn from each other on this. Are there ways of working through this issue in that way?
Briefly, we are talking here about mental health, its reform and on working and finding proper models. Yesterday, a number of members of the Joint Sub-Committee on Mental Health discussed the closure of a mental health facility in my own town, a facility that is working perfectly. It is one of the best which has not had a case of Covid-19 and yet the HSE has decided that it will be shutting this facility next month because of lack of funding for structural issues. What would our witnesses reading be of such an issue? One has a model that has been working perfectly for years but constant Mental Health Commission reports have flagged issues that have not been reacted to by the HSE, where it has not invested in the building. That service could now be lost and the patients in that facility are now to be removed. If I was to have told our witnesses this last year, what would their reaction be to that have been?
Dr. Fiona Keogh:
I will speak on the scope of the all-Ireland piece. On the question on the service that was closed, I am not certain which service Deputy Buckley was referring to. There is a need for services to be continually maintained and upgraded down to basic structural maintenance. Ms Coyle spoke very clearly in her contribution about how €20 million is needed just to maintain the existing level of service. That is part of what the funding is for. Things break and buildings need to be painted, maintained and kept to a certain standard. I am aware that several acute inpatient units need upgrading and, indeed, in some cases new units are needed.
I will speak on the scope for all-island co-operation and perhaps the related issue of out-of-Ireland placements that are made, which comprise a very small number every year. This involves people with very complex needs. Sharing the Vision was quite strong on the need to develop expertise within Ireland and that expertise definitely exists here to support these individuals who should not be exported to other jurisdictions to meet their needs. This can be a very tailored individualised package and can be expensive but we are already paying extortionate sums, in some cases, to have people supported. It is essential to have that expertise and that a funding model to support that is developed in Ireland.
I thank the Chairman. I confirm that I am in Leinster House, LH2000.
There are two points I wish to raise, the first of which is on dieticians. One might say that this does not come into the realm of mental health but it does. I was contacted around this time last year by a number of parents in my constituency to say that eating disorders were spiking again among young people and that there were not enough dieticians in my district of CHO 3 and, indeed, nationally. We organised a campaign within the constituency, which was very good. In March of this year we received confirmation from the Minister, Deputy Donnelly, that a new dietician would be appointed to University Hospital Limerick. Do we an adequate number of dieticians in the country?
Dieticians serve two very important roles. Some people attend them for weight management, including those who suffer from or are trying to manage diabetes but there are also those with eating disorders. That is my first question and I do not mind who answers it.
Ms Fiona Coyle:
I am happy to answer that question for Deputy Crowe. He is really speaking here to the importance of multidisciplinary teams. When we historically think of mental health, we may think of a psychiatrist, psychologist or psychiatric nurses but there is a very important need for a multidisciplinary team, so that the community mental health teams are made up of various disciplines, including dietitians, social workers and occupational therapists. We know that across the country our community mental health teams are not at full capacity and that there is a need to look at that to ensure those positions in place and are delivering the services to the communities. Dietitians play a very important role, in particular, for those with more severe and enduring mental health difficulties. There can be side effects from medication.
Weight can be an issue. I thank the Deputy for highlighting the very important need for a multidisciplinary approach.
I thank Ms Coyle and I will put my next question to her also. Prior to my election to the Dáil I was a primary school teacher. On a typical school day there was a range of school supports for children. There were also outside of school therapeutic supports and supports provided by the National Educational Psychological Service. Throughout the Covid pandemic many of the needs of our young people were not fully met. Teaching was done online and we all got to know about Zoom. We did not know Zoom existed 18 months ago and suddenly the whole of Ireland was using it. Some of the many key therapeutic supports have to happen in person, and I get that, but many could have been offered online. Do we have much catch up to do in this regard?
Will Ms Coyle also weld into her response, if she does not mind, a reply to the following question? In my constituency of Clare I have long had a concern for the rural male farmer. This has been characterised in a number of dramas. Some years ago, RTÉ had a series that portrayed rural isolation and the depression it can lead to. There is a huge campaign about testicular cancer, prostate cancer and male health. The reality is that in many Irish villages we still have rural isolated bachelor farmers. I do not believe their needs are being adequately spoken about. The rural pub was a release for many of them and it has not been there for the past 18 months. They have become more withdrawn as a group. If Ms Coyle would respond to these questions I would hugely appreciate it.
Ms Fiona Coyle:
I might ask Dr. Keogh to contribute on the second question. I understand Mental Health Ireland has a partnership with the IFA in this regard. With regard to e-mental health, before the pandemic Ireland, it is fair to say, was not as advanced as some of its European counterparts in utilising online technology for various reasons such as that the broadband structure needed to be strengthened. Overnight we saw a move from face-to-face to online technology. There is no going back. These technologies are great and perhaps allow us access a larger number of service users but they are not suitable for everyone. Not everyone has the hardware or technology to log in. I have been acutely aware of how expensive video calls are. They eat up data. Many people are in the privileged position of having a contract with unlimited data but for others on pay-as-you-go it can be quite a significant cost. In our pre-budget submission we have asked for funding, particularly for the community and voluntary sector. Overnight these organisations changed their services and they are developing new models of care. We have asked that funding be set aside to support this work in the years to come.
Dr. Fiona Keogh:
Mental Health Ireland carries out activities with regard to individuals, households, communities and workplaces. With regard to communities and workplaces, a small country farm can be a very isolated place. In the past, Mental Health Ireland has partnered with the IFA. We also partner with Coillte and Get Ireland Walking. This highlights the importance of having flexible agile players in the community and voluntary sector that can respond to specific needs by partnering with other organisations with a remit in the area. The need for supports for people in very isolated settings points to the need to build up a real community of support. This is not really about specialist mental health services. This is about having a rich enough diversity of organisations that are attuned to mental health needs and mental health supports and well-being without having to provide a formal mental health service. It really is crucial. The loneliness forum has done much work in this area and has made some very concrete suggestions. It points to the need for a much more joined-up approach across Departments and agencies to address this issue.
I thank Mental Health Ireland, which is representing mental health reform. I am a Senator based in Ballinasloe, which is very much a rural area. Mental health is a huge issue in our area, as is protecting people and making sure they are safe. I read through the submissions and looked at the website. We speak a lot about waiting lists. I am very interested in how we are using innovation to tackle these. The witnesses probably have a number of ideas on this. I posed a question to the Minister on what projects are being done by the e-health section in the HSE that are focused on mental health. Do the witnesses have any ideas on this? We are seeing the largest budget ever for mental health. It will be approximately €1.1 billion this year. It is the largest budget in Irish history for mental health services. It is focused on capital infrastructure and building acute 50-bed units. We need to see more of them. In Roscommon we just have Roscommon University Hospital with a 22-bed unit. We need more in community healthcare west. Some early intervention steps have been taken, such as the community crisis cafe set up in Galway. I am curious to hear the thoughts of the witnesses on this. I believe it is very important, along with ideas such as telehealth. How will we use technology to reduce waiting lists?
With regard to the point made by Deputy Crowe, the submission mentioned the cross-focus between various Departments. Healthy Ireland in the public health section of the Department of Health involves local authorities. "Make a Moove" was an initiative in north Tipperary in an area close to mine. It tackled mental health in farming and how to engage with the cohort of farming families. I want to highlight Men's Shed, which is crucial. There is a very good one in Ballaghaderreen in Roscommon. Pat Towey is excellent. It is a great way to connect communities in rural areas, particularly for older men who sometimes are isolated, particularly over the past year or two.
Dr. Fiona Keogh:
I will speak on the point on Healthy Ireland. The HSE is developing a mental health promotion strategy. Healthy Ireland has been a fantastic initiative and has had concrete and great outcomes from the work it has done. It has always been a bit light on mental health promotion and there is a specific need for activity in this area. The HSE is developing a strategy and it would be great to see it resourced and implemented. Much of the work done by Mental Health Ireland is on mental health promotion. I forgot to mention Men's Shed. It is a crucial part of the community-based infrastructure that supports people who will not show up and have a face-to-face chat with somebody about their well-being. It is very important.
With regard to e-health, Ms Coyle has spoken at length about some of the difficulties and challenges surrounding it. It is a very useful tool. We could start to use it more strategically. Some people really like to engage through e-mental health. These are people who do not want to have a very formal setting. Having consultations through e-health seems to have been very popular with younger people. We have to be careful that it is not seen as the only port or an easy way of filling a gap. It is certainly a very useful tool.
To reduce waiting lists and ensure people are able to engage with a healthcare professional we have to look at what types of technology and innovation we can use to reach out and make sure there is contact. There are a lot of online website resources, such as mymind.org, which is doing online counselling sessions. There is also the 50808 number for text messages for anyone going through a challenging episode. We need engagement in all areas on e-health and pushing how we can make sure our services reach people.
There is no point in waiting for two years for a service if we can find another way to deliver that service or at least the initial engagement that can identify the acute nature of the issue.
Dr. Fiona Keogh:
I agree wholeheartedly. It is a vital tool. Cognitive behavioural therapy, CBT, can be undertaken online and specific therapeutic interventions can be very effectively carried out online. They have been well evaluated and found to produce good outcomes. Therefore, I agree wholeheartedly with the Senator that online provision is increasingly going to be an important part of our infrastructure in responding to people.
Regarding the psychiatry of later life, more robotics are being used when it comes to engaging with people with dementia and enabling them to be more creative and engage their creative sides. Even songs and similar approaches are used to engage with people. Where we may be short on resources, especially, we must find ways that enable one-to-one engagement and particularly with older people. It is a topic close to my heart. Dr. Keogh will be aware that we used to have St. Brigid’s psychiatric institution in Ballinasloe and that wonderful institution delivered acute services. I am aware that the move now is towards a model of more community-based care, but I believe in the importance of acute intervention.
One thing I will be following up on with the Minister of State is how we engage with our front-line services in areas of acute intervention, particularly in the case of the Garda. Mention was also made of the Prison Service, and the prisons are the institutions which are tackling many of the acute areas in this regard. I appreciate that aspect being highlighted. I thank the Chair for the time to contribute, but I do not know if the witnesses will have time to respond.
Ms Fiona Coyle:
Therefore, we have been engaged in the area of e-mental health for a long time and we are happy to follow up by providing some additional information. We can learn a great deal from the Netherlands in this regard and even the UK is much more advanced in this area. Perhaps we can follow up later and provide more information to the Senator.
I thank our guests. This morning has been extremely informative. We have all benefited from the engagement. I was particularly struck by the opening remarks from Deputy Durkan. I agree with many of his comments, especially regarding the lack of 24-7 services. It is shocking that this aspect has not been adequately addressed before now.
Turning to the representatives of Mental Health Reform and its opening statement, I am curious about the €10 million allocated last February but not yet spent. Is there a reason that money has not been spent? Is it due to be spent before the end of quarter 4 of this year?
Ms Ber Grogan:
I thank Senator for his question. He will be aware that sometimes funding is announced on budget day, but when the details are drilled down into it will become clear that some of the funding may have been announced earlier in the year for a different initiative, etc. The onset of the Covid-19 pandemic also meant that other funding was provided, such as the €1.1 million for the community and voluntary sector. The €10 million was announced in February 2021 and we submitted some parliamentary questions asking what it had been spent on. We recently received a reply from the Minister of State to say that her "officials are working with their counterparts in the HSE to identify and develop proposals". Therefore, those proposals are still being examined.
The Minister of State’s reply continued by stating that "it is envisaged that initiatives will be starting in Quarter 4 2021". That is the only information we have. We would like to see that €10 million provided as part of Covid-19 initiatives progressed and spent separately from whatever other measures may be introduced in budget 2022. We are calling for the provision of an additional €85 million in the budget. Drilling down into our pre-budget submission, though, it can be seen that there is a call for the provision of €10 million in the context of mental health services in respect of the Department of Housing, Local Government and Heritage and then another €120 million for the Department of Social Protection, but we did not want to scare the members too much.
That is fine. I totally get it. That brings me onto my next question. Mental Health Reform's pre-budget submission calls for 10% of the overall health budget to be spent on mental health services. Some political parties want to see the extra €4 billion that was provided as part of the additional funding for health services during Covid-19 retained in the health budget. If that were to happen, I certainly hope that the 10%, and maybe even more, of the overall health budget that Mental Health Reform is requesting would be allocated to mental health services.
When the Minister of State attended the Joint Sub-Committee on Mental Health last week she referred to a figure of 5%, and that may be a little higher because of related spending in different Departments, etc. Taking the best scenario possible for spending on mental health services, and including cross-departmental spending in this regard, what percentage would the witnesses think that spending is at in real terms in this regard?
Ms Fiona Coyle:
I am not in a position to estimate that percentage. However, the Government in its Sláintecare policy committed to 10% of the health budget being allocated to this area. I believe that would be based on how the mental health budget is calculated. I read the Government’s commitment in that regard, then, as being 10% based on how the current healthcare budget is calculated.
The Minister of State said it is 5%, but that it would probably be higher overall due to spending in other Departments. Would it be correct to say, then, that in other countries in which the 10% target has been reached that the spending in other departments occurs as an additional?
Finally, because I am conscious of time and other speakers waiting to get in, I am sure Ms Coyle has read the interim report produced by the Joint Sub-Committee on Mental Health. Does she wish to make any observations on that report or was there anything in it that she was not happy with?
Ms Fiona Coyle:
We are delighted that the sub-committee is in place and we commend its work. Its report is reflective of the many meetings it had, including many meetings with members of Mental Health Reform. We again thank the sub-committee and we highlight the important role that the Oireachtas has overall in holding the Minister of State, the Department and the HSE to account. That leadership will be required in future.
Before I call the next Deputy, I have a query. Regarding the idea of a structure to co-ordinate mental health issues between Departments, mention was made of the importance of tying the different approaches together. Do the witnesses have a model or structure in mind that they believe might work? I was previously a member of the all-party committee dealing with disability issues. Representatives appeared before that committee from the Department of the Taoiseach and the other Departments involved in the area. Civil servants also came before the committee from all Departments and they were also tied into the committee. In addition, they came back to the committee with ideas they had regarding how to move that structure forward. As a group, do the witnesses have any ideas in that respect?
Early intervention was also mentioned. We are much better now at recognising children on various spectrums, etc., and, as a society, we are identifying more instances of such needs to be addressed. As a result, that is putting great pressure on services. Depending on the location, people could be waiting up to two years for their child to be assessed and then maybe another two years for the supports to be put in place. Has research been done on the impact that experience has on families?
In particular, there is a lot of anecdotal evidence of the impact that has on relationships. There has been huge strain on the family, in particular, the break-up of marriages, etc., due to those supports not being there.
With the impact of Covid, many of the support groups that we had for mental health and other areas were closed. Some responded through Zoom. In many cases, it did not help. As for the impact that will have on waiting lists, we reckon they will multiply. There will be huge numbers as a result. If we go back to children in those situations who are waiting on those assessments, the waiting list will be longer for those supports to kick-in. Would one see that €10 million sitting there waiting to be spent as one of the areas of priority, particularly for those children?
Lastly, what of those who contracted Covid, in particular, long Covid, and the impact it had on their mental health? I am talking about a lot of people whose lives have completely changed, physically, mentally and in every way. They do not have energy. People who were very fit are no longer able to walk down to the local shop. What of the impact that has on society? Do you recommend that there should be research undertaken into supports for those individuals, but also what we should be doing as a society? What should the Minister be doing, in particular, to support those individuals who have been impacted by long Covid? There are a few questions. Apologies for taking so long. I note Deputy Ward wants to come in as well. Does someone want to respond to that?
Ms Fiona Coyle:
There are a few questions. Probably, the three of us will take some.
As to the question around cross-Government engagement, the other Departments' engagement with the national implementation and monitoring committee for Sharing the Vision will be key. We also need to be reflective and perhaps self-critical of what has not worked in the past. What comes to mind is a brilliant initiative that some may be familiar with - Pathfinder - that was looking at mental health services for young people. That was a multi-Department initiative led by the Department of Public Expenditure and Reform, the Department of the Taoiseach, the Department of Health and then Department of Children and Youth Affairs that was initiated in 2015 and has still not got off the ground. We need to be reflective. Even when we put brilliant initiatives together, why do they not quite work?
I will hand over to my colleagues for the other parts of your question. Thank you, Chairman.
Ms Ber Grogan:
I just wanted to jump in quickly about the research piece and the waiting list for children. What comes to mind is the importance of the community and voluntary sector in this. There is so much research needed and there are community and voluntary organisations working on the ground in areas of their own specialty. For example, Alcohol Action Ireland has the Silent Voices initiative where it is looking at the impact of alcohol on family life and children living in homes with alcohol misuse. There is also the HSE report, The Untold Story, which stated that there would be a further 200,000 children on top of the 400,000 people affected by alcohol homes. There are all of these pieces of research and studies, if we had that structure that would be looking at the overarching aspect of everything. Focus Ireland has a lot of research done on the impact of homelessness on children. There are so many areas from birth inter-generational poverty to inequalities that can impact a person's mental health and can set people up with more barriers and more difficulties. It is about joining all of those dots together.
Dr. Fiona Keogh:
I might speak briefly to the issue of long Covid. There is a developing response within the health service and the recognition that cross-specialty teams, a bit analogous to the cross-Department work we are trying to encourage, are needed. Certainly, mental health would be a component of that support that would be needed.
We are on a learning curve. I was looking at some research from other countries and they are still trying to understand what is going on there.
It would be a good opportunity to - I know rehabilitation services are being developed - include other post-viral syndromes that have been ignored for a long time. I am thinking of one but the name escapes me. Somebody might jump in with it. It was ignored for so long. Anyway, it will come back to me. It is a post-viral long-term condition. It is the same kind of structure. I refer to people whose needs across specialties often fall between the cracks in the health services.
In terms of the cross-Government structures, I am trying to think back. There were some very effective structures ten or 15 years ago around implementing social inclusion policies. The structures need to bring Departments together at a very high level. One needs principal officers or assistant secretaries sitting on these with decision-making authority. The key is a joint funding pot that they are responsible for that goes towards achieving agreed cross-cutting outcomes. That structure needs to be mimicked, probably all the way up to a Cabinet sub-committee and, as the Chairman suggests, also all-party committees, to reflect that. When one has a similar type of grouping cutting across both the Civil Service structures and the Government structures, that helps to improve delivery.
Thanks, Chair. I appreciate the chance of coming back in. I enjoyed the meeting. I got a lot out of it. Like a sponge, I soak up everything that goes on here.
I thank the witnesses and all the members who contributed to the meeting. We got really valuable information.
A question that I am often asked is, how would you fix the mental health services. I heard Dr. Keogh saying that we have to do these things incrementally. It will not be fixed overnight. People sometimes do not want to hear one say one cannot wave a magic wand and fit it overnight, but we can improve people's lives. I think that is all that people are looking for. They are looking for access to services being improved, access to 24-7 emergency mental healthcare and granting mental health care parity of esteem with physical healthcare.
Dr. Keogh mentioned early intervention. Early intervention is key. If we get the early intervention in at the appropriate time, the people who get this early intervention are less likely to need more acute services going forward. Even in monetary terms, and I do not like talking in economic terms, it is economically favourable to get the early intervention rather than provide support at a later time when more acute services are needed. In the primary care services, over 10,000 people are waiting for primary psychology appointments. The vast majority of them are children. We need to start staffing those services. If people can see that there are inroads being made in these, their waiting lists are going down and they are getting access to services, probably not as quickly as they would like but better than they were getting them in the past, that would bring many people with us.
There has been talk about the governance in the HSE and the clinical lead would be something for that. It is difficult to trace any money or governance issues within the HSE, particularly since the cyberattack which has made it even worse because we are not getting any answers back. It is like trying to get information in a vacuum.
They mentioned a cross-departmental approach to this. There is not a decision made at the Cabinet table that does not impact people's mental health. I have always said it. Whether it be housing, economics, health, transport or whatever, whatever decisions are made at the Cabinet table have an impact on mental health and we need to have that mental health voice at the Cabinet table.
Dr. Keogh, Ms Coyle and Ms Grogan talked about the cross-departmental approach and how it would work. I would not have 100% confidence that it would work in its current status. I will give one example.
In my area of Clondalkin, we have agreed funding for a primary healthcare centre. It is currently held up due to a row between the Department of Education and the Department of Health over land in Cork. That is mind-boggling. There is something that is ready to go in Clondalkin, but there is an issue between them in Cork and this is being used as a weapon between the Departments. We need to break down these structures. We must get to a position where civil servants and the Ministers are all involved. Ms Coyle mentioned joint funding that would work across both Departments, but is there any other way she could see this cross-departmental approach to mental health issues working? I would be interested to hear that because I believe that is a missing cog.
Ms Fiona Coyle:
There were many very interesting questions there. In terms of the cross-departmental piece, leadership is important so that there is the commitment of senior civil servants, ideally Secretaries General, if not at assistant secretary level, because unless the decision makers are around the table, progress is slow to happen. That needs to be driven then through political leadership. Although we recognise that change will not happen overnight, there has to be a vision of what can be achieved and there must be both the investment and the leadership to drive forward the reform that is needed.
Dr. Fiona Keogh:
I thank Deputy Ward for his hopeful statement. It is important to give people hope. A ten-year or even five-year costed plan for implementing Sharing the Vision and for seeing how that progress could be made is important. Hope is an important element of recovery for people who have mental health difficulties as well.
I thank the committee for the engagement this morning and my fellow presenters from Mental Health Reform for their role in this.
On that note, we will adjourn the meeting. I thank you all most sincerely for your helpful contributions. I also thank the Sub-Committee on Mental Health, which is continuing its work. Collectively, I believe we need to look at the structure we discussed this morning, if people have ideas. It is one of the missing pieces and we will certainly engage with the Minister and the various Departments to see if we can come up with some type of structure that, hopefully, will bring all those elements together and move the situation forward.