Verona Murphy (Wexford, Independent)
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I wish the Minister of State, Deputy Butler, a good evening and thank her for joining us.

The Minister of State will be well aware of the child and adolescent mental health services, CAMHS, located in Arden House, Wexford. After a three-year absence of a child psychologist, I am glad to say an appointment finally was made in August last.

According to the Government's A Vision for Change document, a full complement of staff, were it to be had, would comprise one consultant psychologist, which Wexford has; and one doctor in training, which Wexford has not, although there is one non-consultant hospital doctor, NCHD. There also would be two mental health nurses, which Wexford has; two clinical nurse specialists; and two clinical psychologists, of which Wexford has one. There would be two social workers - Wexford has one agency social worker - and one occupational therapist, which Wexford has, as well as one speech and language therapist - it has a half-time speech and language therapist. It would have one childcare worker - we have none - and two administrative staff, which we have.

The referrals are being rejected at a rate of knots at CAMHS in Wexford. Basically, Arden House has done no attention deficit hyperactivity disorder, ADHD, assessment since December 2021. Some 46% of all referrals are for ADHD, according to the HSE's statistics, and not one has been carried out in Wexford for six months. I have received numerous representations from GPs who have complained that they sit down with mental health patients, be they young children or adolescents, and they spend a long time filling in arduous forms, only to have them rejected by CAMHS. The services are just not seeing them. I then get representations from the families who make the same complaint. What is happening is that these children end up some weeks later in the department of psychiatry, DOP, in Waterford, having tried to take their own lives. They are referred back by the DOP to Arden House to be seen then. That is just not good enough in any woman's or man's language. Families are in despair that their children are being rejected even though they are being referred by their GP. The worst-case scenario is they try to take their own lives before they are seen.

What has me here today? Before I proceed to that, I want to quote the psychiatrist, Dr. Kieran Moore, who resigned his position in CAMHS three years ago because there were no support services, from a published article he wrote. He is a consultant paediatric liaison psychiatrist. Basically, he was saying the HSE does one thing well and that is hire managers. The extract states:

According to its own website: “the health service executive (“H.S.E.”) in Ireland provides health and social services to everyone living in Ireland.... young and old, in hospitals, health facilities and in communities.” The website also says: “The H.S.E. is required under section 35 of the Health Act 2004 to have in place a code of governance. Governance can be defined as the framework of rules, practices and policies by which an organisation can ensure accountability, fairness and transparency in an organisation’s relationship with its stakeholders.

Almost every employee working in the HSE is regulated externally. However there is no external regulation of managers.

What has arisen today in Wexford is all over national media and social media. A clinical nurse specialist with 30 years experience, and 14 years in CAMHS, is being moved from his position in Arden House to north County Wexford at a time the other clinical nurse specialist is going on maternity leave. Both are being replaced by what is referred to as an acting clinical nurse with two years 'experience to take care of 170 families. I have been inundated with the distressed families who are suffering at the hands of whoever made this decision. I plead with the Minister.

Mary Butler (Waterford, Fianna Fail)
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I thank the Deputy for raising this. We have spoken across the floor many times, and I acknowledge the number of times and the interest she has in mental health services for both young people and older people.

Verona Murphy (Wexford, Independent)
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As does the Minister of State.

Mary Butler (Waterford, Fianna Fail)
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I thank the Deputy.

I wish to make a few points first. With regard to the last point the Deputy made, she asked if I was aware of the crisis situation in CAMHS in south Wexford where a senior clinical nurse specialist is to be relocated to another unit, leaving Arden House, Wexford, with just one clinical nurse serving a 200-patient population. The area director of nursing, who bears overall clinical and operational responsibility for mental health nursing governance, indicates that the rotation of staff at times is part and parcel of a strategic workforce. It is part of efforts to build the capacity for the service and to support continuing professional development for the staff. It is also part of keeping staff motivated and rejuvenated and is an integral part of ensuring high quality and innovative patient care. A number of such rotations have occurred in the past. This week, these rotations are taking place in respect of both adult mental health services and child and adolescent mental health services.

With regard to the south Wexford CAMHS clinical nurse specialist, CNS, the HSE has indicated that the south Wexford CAMHS CNS is moving to north Wexford CAMHS and the north Wexford CAMHS CNS is moving to south Wexford CAMHS on 16 May next. There is, therefore, no diminution of the nurse staff complement in Wexford CAMHS. There will be two CNS posts at Arden House and two CNS posts at Arnold House for north Wexford CAMHS. That is the situation as set out to me.

The Deputy mentioned the multidisciplinary teams. The teams are very important and it was very difficult to get that consultant psychologist into place. It went on for a long time. Since I took office a year and a half ago, we have spent a long time trying to make sure that the post was prioritised and expedited. Thankfully, it has now been filled. I note that the Deputy went through the team. There are some gaps. There are 73 CAMHS teams throughout the country. As a result of what happened in Kerry CAMHS we are doing an audit of every team in the country. The audit is in three parts. One part, which is independent and outsourced, is to look at the composition of all 73 teams in Ireland, the gaps in the teams and to look at governance and whether they are operating to standard operating procedures. I will have all that data available to me.

We are doing another audit, which is also independent and is being carried out by one of the universities. We are going to talk to the children, the parents and the families using CAMHS to see what their experience has been, if they were or were not able to access CAMHS and how they got on. That is the second part. The third part is the piece relating to the audit of potential over-prescribing, which happened in south Kerry. That is a big body of work.

The Deputy mentioned ADHD and said that 40% to 45% of presentations are ADHD. The HSE was clear that it only wanted to audit ADHD presentations, but I was adamant from the start that it had to be a full audit that included self-harm, suicidal ideation, depression and anxiety. In addition, the Mental Health Commission is doing a review in parallel with this, which I also welcome.

Verona Murphy (Wexford, Independent)
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I have to be honest with the Minister of State. The HSE is just not fit for purpose. The Minister of State mentioned that the HSE only wanted to audit the 46% that were ADHD. It would be easy to audit them when it is not actually seeing them. When CAMHS has not done an assessment for six months, what is it going to audit? The next thing it will be telling the Minister of State is that it will not do one for 12 months and it will audit that year, when there is nothing to audit.

The reality is that CAMHS in Wexford has had 28 anorexic patients, but we do not have a paediatric dietician. I have persistently asked for a full-time equivalent to be placed in Wexford. We got no more than a half-time post, but the position has not been filled. How long will it take the HSE to stop looking at its model of employment? CAMHS has been telling me for two years, and saying in writing, that it is following the model set down by the HSE. We must apply on a critical skills basis for people outside the country. Permit employees needs to be done today; it needed to be done yesterday. The Minister of State is sick of hearing it, I am sick of hearing it and, most of all, the patients are sick of hearing it.

When it comes to Wexford, I suppose what the Minister of State said with regard to rotation would make practical sense on some level, but not in this case. I will explain why. The man has been in Wexford for 30 years. He made a written complaint about the consultant psychiatrist. I am telling the Minister of State that now, and that is at the back of this. I am glad to hear there is an audit, because this man will not be moving on 16 May. We will be down a clinical nurse specialist either in the north or in CAMHS in Arden House. He is not going anywhere; he is certainly not moving. He did not ask to move and there is no need for him to move. There are four clinical nurse specialists in the north. There are only two in south Wexford and one is going on maternity leave. She has ten years' experience. Both are going to be replaced with the lesser clinical nurse, one who is acting with less than two years' experience.

I do not mean to raise my voice to the Minister of State. I know perfectly well that she and I have come through this together. We are both learning, but I am learning very quickly because I have been getting the same letters for two years. I cannot stick it anymore. It is not good enough to be providing a service in name only. We have to show the fruits.

Mary Butler (Waterford, Fianna Fail)
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First, these decisions relating to staff rotation are part and parcel of strategic workforce planning. That decision is taken by the local area director of nursing, who is fully entitled to do that.

I want to make a second point.

Over the past two years, I secured an extra €97 million for mental health. It is the largest ever budget. I will always be looking for more when I am in this post. There are some positives out there. As a result of the budget I secured last year, 55 new staff were hired in CAMHS throughout the country. One of them is the psychologist we are speaking about. A total of 45 people were hired for eating disorder teams. A new eating disorder team is coming to CHO 5 this year. It will be in place towards the end of the year. I am building them-----

Verona Murphy (Wexford, Independent)
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Is it for paediatrics?

Mary Butler (Waterford, Fianna Fail)
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It is not for paediatrics. It is for adults first and then paediatrics. I have to put 16 in place and I will have nine at the end of this year. It is incremental. It is the only way we can get the staff and that is what we are doing.

It is important to point out that we know CAMHS is a specialist service for people under the age of 18 with moderate to severe mental health difficulties. It is not for everyone. Only 2% of young people will need the support of CAMHS. Sometimes what happens is that young people are referred to CAMHS by their GP, their family or one of the NGOs but primary care is probably more suitable for them. They are not always accepted. They do not always meet the criteria for CAMHS. This is a clinical decision I cannot interfere with. It is a decision taken by clinicians to determine whether they can give the best support. We have seen an exponential growth in eating disorders. When the clinical programme was devised in 2016 and 2017 it expected 60 referrals. Last year we had 504. Capacity is being pushed and pushed. I am trying to put the capacity back into it.