James Browne (Wexford, Fianna Fail)
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39. To ask the Minister for Health the way in which he plans to deal with the lack of suitable medium to long-term inpatient units for children and adults suffering from severe mental illness and mental disabilities. [23765/18]

James Browne (Wexford, Fianna Fail)
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How does the Minister for Health propose to deal with the lack of suitable medium to long-term inpatient units for children and adults suffering from severe mental illness and mental disabilities?

Jim Daly (Cork South West, Fine Gael)
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I thank the Deputy for his question. A Vision for Change, published in 2006, set out a ten-year policy framework for Ireland's mental health services. It recommended that interventions should be aimed at maximising recovery from mental illness, building on service user and social network resources to achieve meaningful integration and participation in community life. As the Deputy will be well aware, one of the key principles of A Vision for Change was a fundamental move from institutional care to community-based care. The policy advocated for a move towards predominantly community-based care delivered by multidisciplinary teams. In line with this policy a number of old psychiatric hospitals has been closed due to the outdated nature of such facilities. However, the Department recognises that there will always be a need for acute beds. As such, there are currently 1,018 approved acute beds within the HSE.

Investment continues to take place to modernise this area of service and the HSE remains committed to improving rehabilitation services for people with severe and enduring mental illness and complex needs. This includes the new 170-bed national forensic mental hospital complex now under construction at Portrane, to replace the Central Mental Hospital, CMH, along with new facilities such as a forensic child and adolescent mental health service, CAMHS, unit and an intensive care rehabilitation unit, which will open in 2020. The HSE also intends to open an additional ten beds in the Central Mental Hospital as soon as possible once all necessary staff are put in place. New acute and high observation units have also opened in Cork and Drogheda in recent years, with an additional facility in Galway set to be operational in June 2018.

Many of those with severe mental illness and complex needs are discharged from acute inpatient units to a community residence, most often a high support hostel with 24-hour nursing staff available. Community residences provide a structure and support that this group of service users most often need after discharge. They offer an ideal place for further active rehabilitation for those who can acquire sufficient skills to become fully independent and live in their own accommodation. However, for some service users a more intensive inpatient rehabilitation service is required.

In January 2017 a national project was initiated which included developing a model of care for people with severe and enduring mental illness and complex needs. The model of care describes a specialist rehabilitation care pathway that ensures that the requirements of people with severe and enduring mental illness are met.

James Browne (Wexford, Fianna Fail)
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In 1950 there were 7.9 psychiatric beds per 1,000 of our population. The Health Research Board records that the rate of involuntary admission in 2016 was 48.4% involuntary admissions per 100,000 of our population. In England, the rate in 2015-16 was 120. It is almost 2.5 times our rate. EUROSTAT reports that Ireland has the third lowest number of psychiatric beds per 100,000 of the population in the EU. The EU average is 72 psychiatric beds per 100,000 of the population and in Ireland the average is fewer than half that at just under 35 psychiatric beds per 100,000 of the population, a figure questioned by Professor Kennedy only last week to the effect that it might be artificially high. Professor Brendan Kelly states: "These are stark different differences and strongly suggest that Ireland has insufficient psychiatric beds to serve our population."

The closure of inappropriate psychiatric beds in Victorian hospitals was supported in A Vision for Change and rightly so, but are we gone too far in the other direction? Has decongregation effectively become an ideology or a method to cut costs? We are now putting people out of centres into the community where there are not the necessary services in place nor the proper step-down beds or the proper assisted living supports for them.

Jim Daly (Cork South West, Fine Gael)
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The Deputy has made a very interesting point. There is no absolute answer to the query he raised as to whether we have enough inpatient beds. Change is always difficult and the change that was envisaged in A Vision for Change was very dramatic, namely, to move away from inpatient care to community care. As the Deputy will be well aware, it is proving to be an ongoing challenge to ensure we have the supports and staff necessary to provide the care that is needed.

The review of A Vision for Change is ongoing. An oversight group is examining that and we are reviewing it. I am due to meet the group which is reviewing it, I believe, on Wednesday of this week. The question the Deputy raised is still being posed. There is the question of whether we have gone too far or have we gone far enough and, I suspect, the answer lies somewhere in the middle. The provision of inpatient beds is probably being chased from the top. I am trying to refocus the system and have more interventions at an earlier more localised level, whereby we could prevent illnesses escalating and the need for beds at the top. Sometimes when we talk about beds, it can be like treating the symptom, and we can keep producing more beds when we may need to examine what is sending all those people up into the acute space that requires inpatient treatment for mental health.

James Browne (Wexford, Fianna Fail)
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As Professor Kelly stated, the statistics are quite stark and we seem to be going even further down the direction of closing these beds. He stated: "As a result, the key human rights issue in Irish psychiatry today is not disproportionate denial of the right to liberty due to over-custodial care, but, rather, issues concerning the right to access to an appropriate level of care when it is needed, including inpatient care." One of the most common situations with which I deal is just such cases, namely patients who may no longer need to be in an acute unit in psychiatric department but who are not fit to be discharged. I have dealt with patients who have serious dual-diagnosis issues. They are discharged from acute care, they then go to the county council and may be put into bed and breakfast accommodation over a pub. The interim beds that are required are not in place. We have also seen complaints from the forensic mental health services at the central mental hospital where people are being kept in prisons because there is not enough beds there either. There is a serious question to be addressed in that decongregation, in certain respects, is going too far and it needs to be very seriously considered. It is about appropriate care, not blindly applying a particular policy.

Jim Daly (Cork South West, Fine Gael)
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I could not agree more with the Deputy. When e we look at international comparisons and count the number of beds per 100,000 of the population it can be very misleading and unhelpful to the debate. That suggests that a one-cap-fits-all approach works. Countries have different cultures, sources and resources. We have secure hostels with 24-hour staffing and that is a good model that works well. It is a step-down model; it is not one where we take somebody from acute care and put them straight into the community. It is a transitional care arrangement. There is a crisis house down in Tipperary. There are a number of different models in place that can work. We have day patient hospitals and they may be the way to go in the future. People come into the hospital and avail of treatment and supports in the day and return to their homes in the community in the evening. There are a number of different models. A one-cap-fits-all approach would be wrong. If we are to continue to measure our success or otherwise within the health system by using an international yardstick and just counting the number of inpatient beds, that could be very dangerous and could miss the point.