Dr. John Hillery:

I thank the members for inviting us here today. Having listened to the other two presentations, I realise that a lot of what came in the inspector's report echoes the other issues that have come up for the other bodies in this area. I would sum them up by pointing to the need for co-operation, governance and regulation.

We are here to discuss the report of the Inspector of Mental Health Services, which is the independent review of the provision of child and adolescent mental health services, CAMHS, in the State. I am accompanied here by my colleagues, Mr. John Farrelly, CEO of the Mental Health Commission, and Professor Jim Lucey, Inspector of Mental Health Services. Members should note that Dr. Susan Finnerty, the author of this report, has retired and has been succeeded by Professor Lucey. To avoid confusion, I will refer to the previous inspector by name rather than title.

The main point the commission wishes to make is that the implementation of the recommendations made by Dr. Finnerty and the independent monitoring of their implementation must be established immediately so that the public can be assured steps are being taken to ensure the safe and comprehensive delivery of mental health services to children and young people in Ireland. I also agree with Dr. Finnerty’s recommendation that the inspectorate of the Mental Health Commission is best placed to carry out this task. The powers to do this can be granted to the commission under the current legislation.

As members will be aware, the commission is the regulator for mental health services in Ireland. It is an independent statutory body that was established in April 2001. The commission’s mandate is to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to protect the interests of persons admitted and detained under the Mental Health Act 2001. Under the Act, the statutory scope of mental health regulation is limited to inpatient services for children and adults, which are estimated to make up only around 1% of mental health services in Ireland. The figure came as a great surprise when Professor Lucey referenced it on the radio recently. This means every other mental health service in the State, including community CAMHS, is not regulated under the framework of the 2001 Act. Most of the professionals who work in the services are regulated by the professional bodies established to do so, but the systems, the premises and the providers responsible for those systems and premises are not. The Inspector of Mental Health Services does have the statutory power to visit, inspect and report on any premises where a mental health service is being provided. However, neither the inspector nor the commission have the powers to set standards and ensure services comply with these standards by way of monitoring and enforcement.

In her report, Dr. Finnerty recommends that the Mental Health Commission should be given the statutory powers to immediately work with stakeholders and clinical staff to develop standards and rules for the provision of CAMHS community services in Ireland. The general scheme to amend the 2001 Act, as approved by Cabinet 2021, set out the intention of the State to expand the regulation of mental health services beyond inpatient services to the community.

We hope the proposed legislation will come before the Dáil in this term.

CAMHS provides assessment and treatment for young people up to 18 years of age who experience moderate or severe mental illness. CAMHS treats a variety of difficult conditions such as depression, psychosis, attention-deficit hyperactivity disorder, schizophrenia, anxiety, self-harm and other conditions. However, CAMHS are focused on the more serious end of mental healthcare for young people. Dr. Finnerty found many areas of good practice and many dedicated CAMHS staff and teams across Ireland. However, she could not provide an assurance to all parents in all parts of Ireland that their children have access to a safe, effective, and evidence-based mental health service. Some of the findings in the review included: gaps in governance, both at corporate and clinical level; poor risk identification and management, with serious risks unidentified and poor or no response when identified; a wide variation in scope and capacity of CAMHS teams resulting in a postcode lottery for parents and young people; a lack of clinical leadership at CHO and national level resulting in some unsafe practices, inconsistent care and failure to adhere to standards and guidelines; and a lack of central planning to provide child-centred care even though there is an agreed policy. Dr. Finnerty found that the issue of access to CAMHS, or any mental health service for a child, was causing profound distress and frustration to parents who "expressed concern at how their child deteriorated while waiting for an assessment". Dr. Finnerty went on to say: "parents did not know where they can get help and information about services for their child and felt that a crisis needed to be reached before appropriate services are offered to them, or that they have to battle with services before help is provided." She added that many young people and their families are "frustrated, distressed and are trying to cope with deteriorating mental health difficulties while waiting for lengthy periods on waiting lists for essential services". All children have a right to enjoy the highest attainable standard of physical and mental health under Article 24 of the United Nations Convention on the Rights of the Child, which was ratified by Ireland in 1992. Dr. Finnerty stated, "it appears that this right may have been breached for many children with mental illness". She cited the long waiting lists for CAMHS as well as difficulties in accessing primary care and disability services.

Over 1.4% of the population were described as having an intellectual disability in the 2016 census, of whom 24,474 were under the age of 19 years. It is well recognised that children with an intellectual disability have a higher incidence of mental health problems than children who do not. Dr. Finnerty refers especially to problems in service provision for children with intellectual disability and children with autism. Dr. Finnerty found that children’s needs frequently require them to move between primary care, disability services and specialist services such as CAMHS. All such care needs require to be child or young person-centred. CAMHS is a specialist service for moderate-to-severe mental illness and other agencies provide other aspects of a child’s care and treatment needs. In most cases, the needs are complex and extend beyond a single agency. Dr. Finnerty found:

[W]aiting lists across different services such as CAMHS, Community Disability Network Teams or Primary Care services were uncoordinated; that poor relationships existed in many cases between the services, and that joint working was not always in place. There was clear evidence of silos existing in provision of these children’s services with barriers in getting a holistic service based on need.

Dr. Finnerty addressed these matters with four specific recommendations. The first was that the development of the model of care for attention deficit hyperactivity disorder, ADHD, in children and young people must be prioritised, with fast-tracking of the roll-out of ADHD teams in each CHO. The second was that all children’s and young persons' mental health services should be fully integrated so children can move seamlessly between services in a timely manner according to their needs. The third was that the HSE ensure the mental health services for children are a continuum of services and resource these services so they can provide timely interventions whether children or young people have mild, moderate or severe mental illness. The fourth was that there be a single-point-of-contact triage system within each CHO should be developed for all referrals to CAMHS, with the ability to prioritise assessments with community disability network teams and primary care should this be required. This will result in the timely onward referral to the appropriate services and prevent children and young people sitting on waiting lists for CAMHS-provided services for which they do not meet the criteria.

Of course, if people sit on waiting lists for lower tiers of services for a long time, they are going to end up with problems that need more intensive investigation and treatment and they are going to be slower to respond to these. It is the strongly held view of the Mental Health Commission that the HSE, with support from the Department of Health, must immediately start to put together a formal strategy for CAMHS and this must include how all the recommendations, including the four I have just articulated from Dr. Finnerty’s review, will be addressed and how the implementation of the recommendations will be overseen.

The commission welcomes the committee’s interest in the CAMHS report. It sets out a clear roadmap to help ensure that we can work together to restructure services that will deliver evidence-based and up-to-date supports for vulnerable children and adolescents who need such high-level input for their problems and one that we all can, in time, be proud of. The report is practical and straightforward in its recommendations, but unless it is actually implemented it will be just another document on a shelf for future review and regret. I welcome any questions members have and will answer them with the help my colleagues, Mr. Farrelly and Professor Lucey.