James Reilly (Dublin North, Fine Gael) | Oireachtas source

I am pleased to have an opportunity to debate in the House the important issues of mental health policy and services. Mental health and well-being, just as with physical health, are relevant to each and every person in our society. Members will be well acquainted with the complex and sensitive issues that arise where this subject is under discussion.

There has been, and remains, strong cross-party support for A Vision for Change, which was published in 2006. The motion reflects that. This Government has brought a strong and determined focus to the reform and development of our mental health services and we are committed to sustaining this into the future. I would like in particular to acknowledge the determination and commitment which my colleague, the Minister of State, Deputy Kathleen Lynch, has brought to her role as Minister with responsibility in this area since 2011. I want to assure Deputies that she would have been here for this debate had it been physically possible for her. However, she is indisposed following a procedure in hospital.

There is much in the Private Members' motion before the House which is closely aligned with the direction of travel as regards the delivery and reform of our mental health services. I will outline for the House what the current key objectives are and why a sustained commitment will be required for a number of years yet.

In 2006, A Vision for Change was widely welcomed as a progressive, evidence-based and realistic policy document that proposed a new model of service delivery which would be patient-centred, flexible and community-led. Much progress has been made in closing many of the old psychiatric hospitals and providing modern acute inpatient as well as community-based facilities and services.

We have therefore been moving away from the old institutional system of mental health service delivery towards comprehensive care in a variety of settings, including the home, community and in hospital. This common objective requires a change in attitudes generally towards mental health, especially in eliminating the unwarranted stigma that has caused so much pain in the past, as well as prioritising limited resources.

Although implementation of A Vision for Change has been affected by a number of factors, including the changed economic context, constraints in public spending and the moratorium on recruitment, the Government remains firmly committed to reform of our mental health services. This is in line with our clear programme for Government commitment to implement this widely agreed policy, reducing the stigma of mental illness, ensuring early and appropriate intervention and improving access to modern mental health services in the community.

It is in all our interests that we address this issue. Nobody in this House knows just how strong their mental health is until it is tested to breaking point and then it is too late.

A great deal of progress has been made with the accelerated closure of old psychiatric hospitals and the development of bespoke new facilities to support the community-based, recovery-focussed model of care recommended in A Vision for Change. A total of 19 old psychiatric hospitals across the four HSE regions have either closed completely or have closed to new admissions. Closure plans are in place for the remaining old hospitals. However, no closure will take place until the clinical needs of the remaining patients have been addressed in more appropriate community-based settings, in a planned way, and in consultation with them and their families.

Progress also includes the development of child and adolescent or CAMHS services, shorter episodes of inpatient care, the adoption of a recovery approach in delivering services, and the involvement of service users in all aspects of mental health policy, planning and delivery.

Similar to its reports in previous years, the Report of the Inspector of Mental Health Services for 2013 provides a balanced and valuable insight of what has been achieved in mental health and what improvements remain to be effected. None of us would argue with the purpose and objective of these reports, which reflect a realistic picture overall on an annual basis and highlight in an objective way where further work is needed.

While acknowledging that the pace of change towards a modern, patient-centred and recovery-orientated mental health service is slower than desirable, the inspector's 2013 report also highlighted continued progress towards ending the use of outdated and unsuitable buildings for inpatient services and the continued development of CAMHS care.

Last year, following the enactment of the HSE (Governance) Act 2013, I appointed a new directorate to replace the previous HSE board structure. In conjunction with this, the HSE organised the major elements of the services into divisions, each under a national director.

Each national director has responsibility for a defined budget, staffing and other resources and for delivering on specific service targets as specified in the national service plan. The establishment under these arrangements of the HSE mental health services division led by the national director for mental health delivers on a key recommendation of A Vision for Change. This new division carries operational and financial authority, coupled with clearer accountability, for all mental services. We will no longer see money that is put aside for one area being transferred into another area. The budgets will stay within the directorates. The new structure within the HSE has already made a real difference to improving the pace of and clarifying future pathways for developing mental health services.

The HSE national service plan for 2014 commits to a number of key deliverables, including progressing key multi-annual priorities from previous years, implementing access protocols for 16 and 17 year olds to CAMHS and reconfiguring general adult community mental health teams to serve populations of 50,000 each, as recommended in A Vision for Change. As part of the service plan, the HSE has committed to developing an implementation plan for the last three years of A Vision for Change, along with a standard model of care. The national service plan is supported by a detailed HSE mental health division operational plan which sets out how mental health services across all HSE areas will he delivered, following consultation with clinical and administrative staff in each area.

The mental health service is a secondary care service provided in the community and particular emphasis has been placed on the concept of recovery. Access to specialist mental health services is by referral from a GP or primary care practitioner, following assessment of each person's needs. The motion proposes that victims of self-harm should be enabled to present to an appropriate accessible alternative service rather than a standard emergency department. My advice is that such arrangements would not always be clinically appropriate. I note that the Deputy opposite understands this. If by "appropriate" we mean there is no physical or medical risk, we are on the same page. There are specific areas where one would be concerned as a clinician that the diagnosis is not clear on whether the patient has a psychiatric condition or, perhaps, a constitutional condition brought about by a metabolic disorder or, in the case of self-harm, a deep laceration involving tendon and arterial damage that requires extensive resuturing or self-administration of poison requiring stomach wash-out and monitoring, or even renal dialysis. I understand the thrust of the proposal is that, where appropriate, the referral should be to an acute psychiatric centre. Many GPs are skilled in this area and they know their patients. If such a GP is happy that a patient should be referred to an acute psychiatric unit, the patient should not have to endure an emergency department. Sometimes, however, the GP will want the patient to be seen in the emergency department for the reasons I have outlined.

Those with mental illness should have access to the same range of services as the wider community. We must also avoid any stigmatising of individuals who self-harm. Persons who self-harm must therefore first be assessed from a medical perspective to establish whether they have underlying medical conditions which must be taken into account prior to any mental health assessment. The community mental health team is the first line of acute secondary mental health care provision and its presence allows individuals to be supported in their recovery in their own communities. The teams are the primary mechanism for the delivery of community-based mental health care across the full range of mental health services, from child and adolescent, through general adult to psychiatry of old age. These teams provide a range of interventions in a variety of locations, including the service user's home.

The Government has demonstrated its commitment to mental health from the outset. The programme for Government makes a number of commitments on mental health, including ring-fencing annual funding from within the health budget to develop community mental health teams and services. We are also committed to ensuring patients can access mental health services such as psychologists and counsellors in the primary care setting. Early, appropriate and effective intervention is our key message. Since 2011 the Government has delivered on its commitment in these extremely challenging times, where the options for additional expenditure are generally very constrained. A sum of €35 million was made available in 2012, with an equivalent additional amount again in 2013 for new service initiatives. This was augmented by a further €20 million in 2014. This means that, despite serious resource pressures overall, development funding of €90 million has been made available to enhance mental health and suicide prevention. It is the Government's intention that funding for mental health services will continue to be maximised in future years, taking account of evolving resource and health service priorities overall. This will also cover the important area of delivering new infrastructural facilities for the national forensic mental health service. In the context of destigmatising mental health issues, all new primary care centres will be associated with mental health facilities in order that people using these facilities can go in the same door as everyone else.

Our priority capital project in mental health services is replacing the Central Mental Hospital in Dundrum with an appropriate modern facility allied to corresponding development of regional intensive care rehabilitation units. The first phase of the project involves provision of a new 120-bed adult forensic hospital at St. Ita's in Portrane, together with a ten-bed forensic child and adolescent unit and a ten-bed forensic mental health intellectual disability unit on the same site. The project is provided in the agreed HSE capital programme and is proceeding though detailed design and planning stages.

Community mental health teams need to have expertise from all the core disciplines of psychiatry, psychology, social workers, occupational and other therapists, as well as mental health nursing. This must be primarily a people-based multidisciplinary provision. To achieve this end, 1,100 new posts have been funded since 2012, primarily to strengthen community mental health teams for both adults and children and to enhance specialist community services for older people with a mental illness, those with an intellectual disability and mental illness and forensic mental health services in line with A Vision for Change. Some 740 of the 1,100 posts have been filled to date. The recruitment process for the development posts approved in 2012 and 2013 is continuing. Of the 414 posts allocated in 2012, the recruitment process was complete for 395 posts, or 94%, as of the end of May 2014. Of the 477 posts allocated in 2013, the recruitment process was complete for 326 posts or 62%, as at the end of May, with the remaining posts at various stages of the HSE recruitment or approvals process. There are a number of posts for which there are difficulties in identifying suitable candidates due to factors including availability of qualified candidates and geographic location. This is not unique to the mental health services. Options to enable more local recruitment are also being considered where this will assist in filling specific posts. I have received assurances from the HSE that the recruitment process for all new posts is being given priority. A further 250 to 280 development posts have been earmarked for this year. This will add capacity among the required range of health care professionals to deliver the community-based care which is at the heart of A Vision for Change.

Acute inpatient admissions for children and adolescents are prescribed in A Vision for Change as relating to age-appropriate acute inpatient units, which are approved centres registered with the Mental Health Commission. The provision of inpatient beds is integral to the range of services required to meet the needs of young people appropriately. Interventions are provided through community mental health teams in the first instance and, if required, access to relevant inpatient services is provided. The need for inpatient treatment has decreased greatly for both adults and children with modern techniques of counselling and medication. Nationally, bed capacity for children and adolescents has increased from 12 beds in 2007 to 56 at present. In 2008, only 25% of admissions of children to HSE acute inpatient units were considered age appropriate. By 2013 this figure had increased to almost 80% of admissions. While this is still not acceptable or in line with Mental Health Commission regulations which require that all children under 18 should be admitted to age-appropriate acute inpatient facilities except in exceptional circumstances, clearly significant progress is being made on this issue.

The ring-fenced funding allocations provided by the Government since 2012 have allowed for 230 appointments in the area of mental health services for children. Approximately 80% of these are in place, with the remainder being recruited. This is proof of our commitment to improve these vital services. The admission of children and adolescents to age-appropriate CAMHS inpatient facilities reflects best practice and supports better outcomes for the individuals concerned. This is a key priority for the HSE in its service plan for 2014. We have developed a specific quality key performance indicator to ensure the focus remains on meeting that objective.

After A Vision for Change was launched, an independent monitoring group was appointed to oversee implementation of the policy.

This group reached the end of its term in 2012 and A Vision for Change contained a commitment that it would be reviewed after seven years. The current priority, however, is to review the Mental Health Act 2001, after which consideration will be given to reviewing A Vision for Change and determining appropriate monitoring arrangements for any updated or successor policy. In the mean time, the HSE continues to implement the strategy and reports on a monthly basis in line with the performance reporting arrangements in place for the national service plan.

ReachOut, the national strategy for action on suicide prevention for 2005 to 2014, will come to the end of its ten-year term this year. Consequently, at the request of the Minister of State, Deputy Kathleen Lynch, earlier this year my Department and the HSE began work on a new strategic framework for suicide prevention for the period 2015-2018, building on the comprehensive work delivered under the current ReachOut strategy. The aim of the new framework will be to support population health approaches and interventions that will assist in reducing the loss of life through suicide while aiming for improved co-ordination and integration of services and responses in this area. The objective is to have the framework completed by the end of 2014. The work in hand includes consideration of a wide range of national and international evidence and existing good practice, addressing areas such as research, policy, practice improvement, engagement and communications and media. The process also incorporates a review of the implementation of ReachOut, a public consultation process and a review of the evidence base for suicide prevention initiatives. The strategy will be focused on a whole-of-Government approach.

General practitioner and primary care teams are often the first point of contact for a distressed person seeking assistance. The suicide crisis assessment nurse, SCAN, model, which allows for crisis interventions at primary care, is being rolled out this year, with eight new services to commence shortly. This service provides active liaison between primary care and mental health services. Built on a clear evidence base, the SCAN model brings confidence to health practitioners in choosing a care and support pathway for an individual. The locations for this initial phase are north and south Dublin, Waterford, Cork city, Galway, Sligo, Donegal and Laois and Offaly, in addition to an existing service in Wexford.

I acknowledge there is more to be done in developing a focused recovery and person-centred orientation for some patients. The problems and suffering associated with severe mental health problems are complex but there is a growing recognition that with a recovery approach, it is possible to live well despite any limitations caused by disability or illness. Deputies will be aware that on the legislative front this Government has made significant progress with the publication of the Assisted Decision-Making (Capacity) Bill 2013 and the establishment of an expert group to review the Mental Health Act 2001 which is expected to complete its final report in the autumn.

There is much more in the document before me, which was clearly designed to be read in a much longer slot. With regard to electro-convulsive therapy, ECT, we must always remember this treatment has a role which must be protected, and clinicians must be allowed to make a determination when somebody is not compos mentis. If somebody is psychotic, he or she is not in a position to make a value judgment, although the family may have a view, which should always be taken into consideration.

Prevention is better than cure and the launch last week of Healthy Ireland is as much focused on mental health as it is on physical health and well-being. It is important to state clearly that well-being reflects the concept of positive mental health, in which a person can realise his or her own abilities, cope with the normal stresses of life, work productively and fruitfully and be able to make a contribution to his or her community. Healthy Ireland highlights the need to combine our existing mental health promotion programmes with interventions that address broader determinants and social problems as part of a multiagency approach, particularly in areas with high levels of socio-economic deprivation and where fragmentation occurs.

We recognise the need to prioritise the mental health needs of vulnerable groups. As politicians, we hear tragic stories all too often which are directly associated with the economic crash in recent years, and as people have noted, nobody in this House is unaffected by this, with friends and family having suffered. The economic problems have put tremendous pressure on people. I know HSE mental health staff are keenly aware of the need to ensure that where treatment and care is required in these circumstances, it is provided as quickly as possible and in the least restrictive manner possible, consistent with the wishes of the individual. The expansion of our community mental health teams is an important step forward in this regard.

I saw Deputy Adams at the gay pride parade, which I attended last Sunday, and in the course of the events I came across some other information relating to mental health. It indicated that attempted suicide is seven times more common in teenagers who are gay or lesbian. Groups such as this must be supported, with strategies put in place to help them deal with these issues.

I thank the Opposition for raising this very important issue. I accept there is still work to be done but I assure the House of the Government's continuing commitment to implementing A Vision for Change and reforming our mental health services to ensure people can access modern patient-centred and recovery-oriented care.

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