Róisín Shortall (Dublin North West, Social Democrats) | Oireachtas source

Thank you. I would ask that you give this further consideration ahead of Committee Stage.

In respect of CAMHS, I would like to jump ahead to Part 6 of the Bill, the regulation of mental health services. I will return to other important provisions but, as the Minister of State will know, this is an issue I have been pursuing with her for some time. While I very much welcome the inclusion of community CAMHS regulation in this Bill, it is hard to understand why this was not progressed earlier via a short amendment Bill. It is over a year since the Mental Health Commission's final report and well over a year and a half since its interim report, both of which clearly recommended immediate regulation of CAMHS. In fact, it was its primary recommendation. Families for Reform of CAMHS appeared before the health committee last January and they also stated that it was their number one priority, yet it still has not happened. Given the condition of children's mental health services in this country, this delay is very regrettable. It is frankly unforgivable, in my view, that even when we had report after report into the sorry state of CAMHS, the commission still does not have the powers to intervene in community CAMHS services. I accept that root and branch reform of CAMHS will not happen overnight but this is not a new problem. The very least the Minister could have done was progress regulation. Now well over a year has been lost when the commission could have been working with CAMHS teams to develop standards and rules and address serious shortcomings in the service. This is a service relating to children, and years lost from childhoods are really never regained. In circumstances where we are talking about children with mental health issues, there has to be a real sense of urgency in respect of those services because of the damage done to those early years, which sometimes remains with the person throughout their adult life as well. Dr. Finnerty's report should have been a catalyst for change but the response should have been speedier.

Next I would like to speak to Part 2 of the Bill, the guiding principles. I welcome their inclusion and in particular the distinction between adults and children. This new Part represents a significant shift in approach and acts on a key recommendation from the expert review group. When it comes to involuntary admissions, the 2001 Act states that the best interests of the person must be the most important consideration. While the best interests test is a core principle in respect of decisions related to the care of children, as we know, it is not an appropriate assessment tool in the care of adults. I am pleased to see that the new guiding principles will replace this paternalistic model with one that presumes individuals have the capacity to make decisions about their treatment in line with the Assisted Decision-Making (Capacity) Act. During pre-legislative scrutiny, Dr. Fiona Morrissey from NUIG's centre for disability law and policy articulated the importance of this presumption. She asked how any of us would like to be treated if we found ourselves in this situation. Would we like to be listened to, supported and have our wishes and human rights respected? After all, we are all vulnerable to periods of mental distress. Dr. Morrissey also cited recent studies which found that most mental health inpatients had full or partial capacity, higher than that of physical inpatients. It is quite an interesting finding. We need to challenge our assumptions and ensure that a culture of coercion does not pervade our mental health system, as it has unfortunately so often done in the past. After all, involuntary admissions should only ever be an absolute last resort.

Returning to the guiding principles for children, I agree that the paramountcy principle should be retained for minors. However, their views should be given due weight in accordance with their age and maturity. That is why it is welcome that the will and preferences of minors receive greater recognition in this Bill and that it provides for a bespoke set of arrangements for 16- and 17-year-olds on the cusp of adulthood. This will allow older children to be involved in the conversations around their care. Furthermore, it will bring the presumption of capacity for 16- and 17-year-olds into line with physical health.

When it comes to involuntary admissions, the provisions of the Bill are certainly a significant improvement. According to the College of Psychiatrists of Ireland, just under 2,500 admissions to psychiatric units in 2020 were involuntary, of which just under 950 were admitted for the first time. Many people may find is surprising that we could still be at that kind of level in the very recent past. Clearly something is amiss and more than 60% were readmissions. This indicates a community and primary care service that is chronically underfunded and under-resourced. I will return to this point later. The revised definitions of the terms "risk" and "treatment" in respect of involuntary admission are also welcome but this matter will require greater scrutiny on Committee Stage.

When it comes to applications, the disqualification of gardaí is to be welcomed. They can still be involved in the involuntary admissions process but the Bill places greater limitations on their role. Last year, An Garda Síochána accounted for the highest number of involuntary admission applications at 32%. That is quite high and certainly of concern. However, I am aware of a number of circumstances that arose, for example, in the middle of the night, at weekends or over the Easter or Christmas period when nobody else was available to intervene except the Garda. It is easy to point the finger at the Garda, but for families that are in difficulty with a family member who has real issues, gardaí are very often the only ones available to provide help and it is important to bear that in mind. Of course, that is a significant reflection on the fact that our out-of-hours services are so abysmally poor.

People often present at a very crowded accident and emergency department where staff are under enormous pressure and, in many cases, there is no chance of the necessary help and support or even advice being available as to whom that person can turn. The Mental Health Commission has previously raised serious concerns about this practice and called for the removal of gardaí from the list of eligible applicants but there must be alternatives in terms of support and help available to people.

The Irish Council for Civil Liberties continues to have concerns about the role of gardaí and the detention provisions contained in this Bill. While I certainly agree with that in principle, very regrettably there are occasions when a Garda station is the only safe place for a person because there is nowhere else for a person with serious mental health issues to go. Again that is a very poor reflection on the lack of priority that has been given to mental health services.

As noted during pre-legislative scrutiny, Garda stations can be extremely challenging but, as I have said, very often there are no alternatives. On Committee Stage we also need to take a closer look at the role of family members in the involuntary admissions process. The Bill still allows for them to make applications for involuntary admissions. I can understand the rationale for that. However, there are mixed views about their inclusion. The expert review group stated that only authorised officers should be able to make involuntary detention applications. I can understand why many families would want this option available to them, but I believe this requires further scrutiny, not least given the risk of long-term damage to family relationships.

On a related point affecting young people, a family member can sometimes be kept entirely in the dark as to the nature of their loved one's condition. They are very worried about them. They do not know what is happening to them. They do not know what services might be available to them. Very often family members who mean very well and are very supportive of their loved one are kept in the dark completely as to what is happening. I think there needs to be some way. I totally respect patient confidentiality and all that, but very often with people who have mental health difficulties, their therapist needs to talk to the entire family. There is an issue with the complete exclusion of family.

Several other provisions will also need to be carefully teased out by the Select Committee on Health on Committee Stage. Alongside this work, we must also consider possible ambitions in this Bill which have been identified by Mental Health Reform, namely the admission of children, of course, into adult as psychiatric units which must end. The way it has to end is by providing appropriate children services. However, for that to be realised, the Government needs to commit to providing the necessary resources. The State is still only spending half of the recommended 10% of its overall health budget on mental health. Sláintecare was very clear about this. Best practice is that 10% of the overall health budget should be devoted to mental health services. As we are only at approximately half that at the moment, there is significant way to go. By comparison, the UK spends between 13% and 14% of its health budget on mental health.

Arguably recruitment has been the biggest challenge facing our health and social care services in recent years. I am not going to go there at this at this point but additional university places must be provided. More importantly, clinical placements must be provided by the HSE. Very often the lack of appropriate clinical placements for people and training is the cause of the shortage of adequately trained people. We must have that joined-up thinking between higher education and the Department of Health and the HSE.

The optional protocol is really important. The Minister of State has committed to it but we need a timeline.

My last point is about the over medicalisation of people with mental health issues. Too often services are determined and dictated by psychiatrists when it should be ensured that adequate talk therapies are available. We also need to invest in psychology in primary care and in psychotherapy. Obviously, there is an important role for medication in the treatment of persons with mental health difficulties but because talk therapies are not available and because a once-off or twice-off appointment with the psychiatrist may be the only option available, too often medication is prescribed. We need to reduce that and reduce the medicalised model of mental health services and ensure that there are adequate talk therapies. That especially applies in the case of children. I thank the Minister of State for the Bill.

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