Professor Matthew Sadlier:

The Irish Medical Organisation thanks the committee and the Chair for the opportunity for me and my colleagues, Professor Kelly and Vanessa Hetherington, to present to them today.

We have a number of concerns related to the Mental Health Bill 2024, particularly in regard to the criteria for involuntary admission and the procedure for patients who lack decision-making capacity and decline treatment. Patients who require voluntary or involuntary admission to a psychiatric unit are among the most ill and vulnerable in our society and require timely and accountable care. While the intention of the Bill is to ensure the protection of patients’ rights with regard to autonomy, the provisions, which create a dual process for involuntary admission and consent to care, are legally, clinically and logistically impractical and could deny patients with serious mental illness the right to timely, and often life-saving, medical treatment.

There are already significant workforce deficits. Based on our current population, we need about 760 consultant psychiatrist whole-time equivalents, but we cannot fill 30% of the 570 current approved posts.

The IMO’s main concerns are the following. First, the criteria for involuntary admission states that admission is “immediately necessary for the protection of life of the person or that of another person, or ... necessary for protection from an immediate and serious threat to the health of the person, or that of other persons”.

The use of risk as an admission criteria asks mental healthcare professionals to do something that lacks a firm evidence base. Predicting risk is not scientifically possible. Thus, the risk criteria should be removed.

The provisions for consent to treatment under section 3 create a dual process, one for detainment and a second process for treatment. This has the potential to significantly delay the treatment of involuntary patients with severe psychiatric illness. Allowing patients to be detained without treatment will result in a further decline in the patient’s condition, prolong distress and lead to potential long-term adverse outcomes. The suggested method of accessing treatment through court orders will result in a waste of precious medical time as well as court and other State resources. Effectively, where a patient is found to lack capacity to consent to treatment, the Bill would lead to a situation where, rather than treating patients, consultants and multidisciplinary teams would be required to make an application to the High Court to provide necessary and often life-saving treatment to these patients. With approximately 2,000 involuntary admissions a year, where many patients will lack capacity, the proposed system will put an inordinate strain on our courts and mental health services. This will lead to knock-on effects on waiting times for patients waiting to access the system as too much of our time will be taken up with court procedures.

Patients' decision-making capacity should be assessed at the time of admission, with due consideration to supports available under the 2015 Act, with the same criteria for admission and treatment. This would make the admission order an admission and treatment order, which would be better for patients and the service and would just make sense, to be honest. For additional oversight, a second opinion on capacity could be provided by an independent consultant psychiatrist appointed by the Mental Health Commission and subject to ongoing review.

The section on psychosocial assessment at the time of admission or change of admission status is not necessary for the urgent treatment of severe mental illness. Psychosocial assessments are a critical and important part of a recovery journey. However, making them part of an involuntary admission procedure could potentially lead to a situation where patients are more likely to have their liberty constrained based on their social circumstance, thus creating a two-tier detention process.

On regulations for care plans, where a Minister can determine the content of care plans represents a significant and unprecedented regulatory and political interference in clinical care and the doctor-patient relationship. Patients are entitled to a collaborative individualised care plan based on the best available options, not based on political edicts from non-clinicians.

In a number of areas, the Bill proposes to place statutory responsibility on clinicians, either consultants and clinical directors, for administrative tasks they have no ability to control. These include the responsibility for obtaining staff to conduct second opinions, psychosocial assessments and the responsibility for transporting patients to an approved centre. Clinical staff members do not have the authority to compel staff or approve budgets to allow these things to happen. What should be in the Act is an agency created by the HSE that runs 24 hours, seven days a week, which can fulfil these administrative functions and let clinicians do what clinicians should do.

Under section 28(3), a person may be directed to give evidence to a review board at a specific date and time without consideration of that person's other workload. This could have a significant impact on service delivery, with cancellations of outpatient clinics and other services, if it is not done in consultation with staff in trying to accommodate staff schedules.

Part 6 expands the remit of the Mental Health Commission to include inspection of community mental health services. When inspecting mental health services, the Mental Health Commission should assess not only the service but also the budget allocation received by that service to ensure services are adequately funded. Inspections should also include an assessment of appropriate staffing levels within services and HSE recruitment services, and the effects of national policy on individual approved centres and community centres, including external factors that affect a centre's ability to comply with regulation.

I once again thank the committee for the opportunity to present today. We are aware amendments were proposed and published yesterday evening that may address some of our concerns, but these are obviously not yet accepted as part of the Bill.