Michael Harty (Clare, Independent)
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I wish to raise the state of the psychiatric services in west Clare but these problems are reflected nationally throughout the psychiatric services. In west Clare, we have not had a psychologist in the community psychiatric service for the past six years and this is putting huge pressure on other aspects of the health services. We only have a half-time equivalent social worker and for the past six weeks, we have not had a consultant psychiatrist. Recruitment of experienced psychiatric nurses is an issue but because of the deficiencies in the membership of the community psychiatric team, clinics regularly have to be cancelled. Emergency cover is often only provided from other sectors.

Junior staff are prevented from practicing fully in an unsupervised role. As the staff left behind are just burning out, we have a huge deficiency in the membership of our community psychiatric teams. This situation is not unique to Clare. In the Oireachtas Joint Committee on the Future of Mental Health Care recently, we heard from Dr. Kieran Moore from County Wexford. He and two of his colleagues are resigning from the psychiatric services in the Wexford area because they find that what they are being asked to do is unsafe and unfair to their patients. Rather than continue to work in an unsafe and unfair manner, they have decided to resign. This a poor reflection on our psychiatric services and we do know that recruitment and retention is a huge issue right across the health service but particularly in the psychiatric services.

Again, at the Oireachtas Joint Committee on the Future of Mental Health Care two weeks ago, we discovered there are 25 different hoops that must be gone through before a member of staff can be recruited. That is before looking for a member of the medical profession to actually take up a post. There must be huge deficiencies in how we are managing recruitment and retention issues. The most common requirement for people in the front-line staff, particularly general practitioners, GPs, is access to counselling and to psychologists. Not every patient with a mental health issue has a biochemical abnormality, yet because talk therapies and counselling are not available and because psychological services to deliver non-medical therapies such as cognitive behaviour therapy, occupational therapy and all the other therapies that go to help people who have mental health issues are not available, there is an overreliance on medication.

We heard, again at the Oireachtas Joint Committee on the Future of Mental Health Care, that €400 million is spent on medication in the mental health services and only €10 million is spent on talk therapy, psychological therapy and counselling. Medication obviously has an important part to play but the disparity and imbalance between what we are spending on medication and what we are spending on counselling is unacceptable. Talk therapy and access to psychology and counselling is extremely important yet many of our community psychiatric teams are lacking in those disciplines.

We need to have one-to-one therapy with patients. The issue is that there must be continuity of care, there must be one-to-one therapy with people and they must know that they have a person they can contact when they have a problem. What is happening at present is that our services are disjointed, there is no continuity of care and there is no consistency in providing staff. Some areas have excellent recruitment and retention and others have not. I ask the Minister of State how consistency can be brought across the board.

Finian McGrath (Dublin Bay North, Independent)
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I thank Deputy Harty for raising this important issue and I commend his own work in respect of the health issues, particularly in his own native county but in the national debate as well. It is essential that we acknowledge the work that many of our colleagues do. My colleague, the Minister of State, Deputy Jim Daly, is aware that west Clare has faced difficulties in locating a consultant locum to provide cover for a consultant who began maternity leave on 14 May this year. I accept that point. The good news, though, is that the HSE is confident that a locum consultant will be in place on 9 July. It has informed the Minister of State, Deputy Jim Daly, that as an interim measure, the executive clinical director has run two clinics in early June in Kilrush and Ennis and a registrar has continued to provide outpatient reviews. Until the placement of the locum consultant, the executive clinical director will continue to attend a number of clinics.

The clinical director is also in regular contact with the staff in Kilrush, providing support as required. The west Clare inpatients in Ennis are being supervised by two other consultants, which will continue until the arrival of the locum. In respect of the broader mental health services and supports, I am glad to say that the local action plan, Connecting for Life Mid-West, was launched in April 2017. This local implementation action plan is based on the same vision, goals, objectives and measurable outcomes as outlined in the national strategy, Connecting for Life, Ireland's National Strategy to Reduce Suicide 2015-2020. Together with identifying the local statutory and non-statutory mental health services and supports in the area, it sets out specific local actions based on the feedback received from a public engagement process in May 2016 and the best available evidence relating to suicidal behaviour.

On a national note, I would like to reiterate that the strengthening of the mental health services is a priority for the Minister of State, Deputy Jim Daly, and for the Government. The mental health budget has risen from €711 million in 2012 to €912 million in 2018. That is an increase of more than €200 million, or approximately 28%, in six years. The Minister of State, Deputy Jim Daly, has already secured agreement from the Minister for Public Expenditure and Reform that the budget will increase by a further €55 million in 2019. Other positive activity to note in this area includes increased staffing levels, the introduction of new posts, improved seven-days-a-week response and liaison services, as well as continued work on clinical programmes. In April, 10,008 staff were employed in mental health services. Staffing levels in mental health services show an increase of approximately 193 when compared with the April 2017 figure. In excess of 2,000 new posts have been approved since 2012 up to the end of 2017, of which some 1,352 have been recruited or are in the recruitment process.

The level of vacancies, the difficulty in recruiting skilled staff and the substantial increase in demand pose a significant challenge. The provision of 136 new primary care psychologists, including 22 basic grade psychologists and 114 assistant psychologists, will, however, help to reduce pressure on these services.

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We will also provide funding to increase psychiatric nurse undergraduate places by 130 per year by 2021-2022. In the context of an improved seven-days-a-week response and liaison services, the HSE is now in the final stages of recruiting staff required to deliver the 7-7 mental health service cover for the areas that do not currently have such a service in place.

In summary, the Irish mental health service faces challenges, including increasing demand for these services and the difficulties in recruiting and retaining staff. I am confident, however, that the steps we have taken will ensure that we meet these challenges.

Michael Harty (Clare, Independent)
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Most of the reply from the Minister of State refers to patching up deficiencies in services, particularly in west Clare. The answer he has given offers only stop-gap solutions. When speaking about recruitment and retention last week, the Minister of State at the Department of Health, Deputy Jim Daly, indicated that, in the context of the challenges that are arising, there should be telepsychiatry in the future. In other words, psychiatric services will be delivered to those who need them from a remote site. This is how he intends to deal with the problem. We all know that one-to-one consultation and continuity of care are so important for people with mental health issues.

The Minster of State made no mention of the fact that west Clare has not had a psychologist in place for the past six years. This is a huge deficiency in terms of service. The social services in the area are also deficient; we are now down to a half-time equivalent supply. Almost half of the budget increase in the mental health sector this year has been used to employ agency staff. It would appear that the main focus on dealing with the recruitment and retention issue is to employ agency staff. Failing that, the new solution seems to be telemedicine and remote treatment in respect of mental health issues. This is totally unacceptable.

The Minister of State mentioned that 2,000 jobs have been approved in the area of mental health services. However, many of those jobs have not been filled and remain vacant. Recruitment and retention are major issues. The problem is that the pay and conditions and the infrastructure are not satisfactory, and there is no support from management. The morale of the service is so low that it is almost impossible to recruit people. Many of our nursing graduates are emigrating en masse once they receive their qualifications. These issues must be addressed.

Finian McGrath (Dublin Bay North, Independent)
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I take the points made by the Deputy about the Clare region. The locum consultant will be appointed on 9 July. I also agree with the point he made about one to one services. It is a very crucial aspect of psychiatry and psychology. I will bring to the Minister's attention the concerns he has raised about the large number of agency staff used by the service.

It is important to remember, despite some of the criticisms - and I accept that the Deputy has made genuine, valid points - that the level of vacancies and the difficulty of recruiting skilled staff continues to pose a significant challenge to provision of service. This is particularly the case with child and adult mental health services, CAMHS. That is a sad reality. The provision of 136 primary care psychologists, including 22 basic grade psychologists and 114 psychologists, aims to reduce this pressure. There is an issue about staff, and I accept the points made by the Deputy, but of the 22 basic grade psychologist posts 20 are currently filled. We also face difficulties in recruiting nurses, and the issue of undergraduates as well.

I take the points the Deputy has made and I will bring them to the attention of the Minister of State, Deputy Jim Daly. If we are investing the money - and the budget is available - we need to ensure that the services are up and running. They must be patient-led and the vision for our psychiatric and mental health services has to be developed in a positive and constructive way. We are committed to doing that.