Dáil debates

Thursday, 26 January 2023

Interim Report on Child and Adolescent Mental Health Services: Statements


4:24 pm

Photo of Stephen DonnellyStephen Donnelly (Wicklow, Fianna Fail)
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Go raibh maith agat a Cheann Comhairle and I am sharing time with the Minister of State, Deputy Butler. The Mental Health Commission's interim report is an important contribution to our objective of providing timely high-quality child and adolescent mental health services, CAMHS. The focus on service quality and patient safety is vital in developing and improving services. Following the Maskey report early last year, the Minister of State, Deputy Butler, contacted the Mental Health Commission to ask it if it would consider conducting a review such as this into CAMHS services. The Mental Health Commission is independent and ultimately chooses what it wants and both the Minister of State and I were glad that they decided to focus on CAMHS this year. The findings in this interim report are significant. The report makes for very sober reading and is being treated as a priority by the Minister of State, Deputy Butler, and me, by the Government, by the Department of Health and by the HSE.

The findings in the interim report are significant. It makes for very sober reading and is being treated as a priority by the Minister of State, Deputy Butler, and I, as well as the Government, the Department of Health and the HSE. The findings identify issues that are simply not acceptable to me, nor are they acceptable to our healthcare professionals providing these services. Many of the issues raised are being responded to by the HSE, and the Minister of State and I are engaging with the HSE and the Department of Health on what additional actions are warranted on the back of these findings. We are also hearing from front-line clinicians, from excellent groups such as Mental Health Reform, which are here with us this evening, and from professional bodies.

The report is one of several important pieces of work under way. These include an improvement plan, addressing issues identified in the Maskey report, many of which have been highlighted in the interim report. There is an audit ongoing on adherence to the agreed 2019 national guidelines. There is an audit on prescribing practices. There is a listening exercise, which is very important, that is focused on engaging directly with service users and their families. A look-back review into cases in north Kerry is being commenced and, critically, the HSE is commencing a review of all open child and adolescent cases that have not been monitored for six months or more. One of the issues highlighted in the interim report is the need for such a review. In fact, it was one of the main asks of the Mental Health Commission, and the HSE has immediately agreed to do that and is undertaking it. The HSE estimates there to be approximately 4,000 such cases. The interim report references 168 cases. The HSE has engaged with 140 of those already and is looking at the remaining 28 cases. I also look forward to the final report, which will come out later this year. Coupled with new national leadership positions in CAMHS, and guided by the national strategy for mental health, Sharing the Vision, these different areas of review are informing what additional actions are required to achieve what we all want which is consistently high-quality and accessible mental health services for young people.

As the programme for Government outlines, we are committed to a high-quality, safe and compassionate mental health service for children, women and men. In addition to ongoing and increased funding for mental health services, a focus on service improvement and reform is essential. It is important to say that in spite of the challenges we are discussing this evening, good progress is being made on many fronts, and the Minister of State, deserves great credit for her ongoing work and championing of changes and improvements that patients need to see.

I fully empathise with young people and their families who may be worried about receiving the care they deserve. This came to the fore with the publication of the Maskey report and was highlighted again this week. I thank Dr. Susan Finnerty and her team for their valuable contribution so far in both the interim report and final report that will come. I also recognise the important and good work done by CAMHS teams across the country. I thank them for their ongoing commitment to young people and their families. It is important to emphasise that many young people experience a positive outcome with the support of CAMHS.

It is important for us to reflect that the interim report quite rightly calls out the things that need to change, but it also makes important points about what is working. It states that 225,000 appointments took place last year under these services. Some 21,000 young people are being supported by CAMHS. Critically, the interim report states that many young people, and their families, have received "excellent care and treatment" and we must keep that in mind.

To the credit of the 73 CAMHS teams nationally, they have turned additional funding and supports from the Government into a 21% increase in the number of new patients being seen. Let us think about that for a second. In spite of all the challenges and difficulties that Covid caused for patients, their families and service providers, our CAMHS teams increased the number of new people being seen by 21% and that must be acknowledged. The problem is that demand for services rose by 33% during the same period. There is no health service in Ireland, and I dare say very few anywhere, that could absorb a 33% increase in demand in a short period and not come under significant pressure. It would not be any different with our CAMHS services.

While the work and reviews are ongoing, we must ensure that people are receiving appropriate care today. Acknowledging the serious concerns raised in the report, I remind all those using CAMHS, and their families, that HSE Live is available to support children, young people and families with concerns arising from the interim report. The telephone number is 1800 700 700 and lines are open Monday to Friday from 8 a.m. to 8 p.m. and Saturday to Sunday from 9 a.m. to 5 p.m.

What of the overall direction for mental health and youth mental health services? The HSE is essential in implementing the recommendations of Sharing the Vision and it sits on the national implementation monitoring committee for the implementation of the 100 policy recommendations. Progress is being made on the implementation plan. Sharing the Vision aims to enhance mental health services and supports up to 2030, from mental health promotion, prevention, and early intervention to acute and specialist mental health service. With improved links to youth mental health services in the widest sense, CAMHS is crucial to Sharing the Vision. As of the third quarter of 2022, some 88 of the 100 actions are in implementation stage, with 57 marked on track. I have no doubt we would all love to have the 100 actions marked as on track, but we must bear in mind that our health services providers, the people tasked with doing this, have been dealing with the most difficult health care crisis in 100 years at the same time. We must bear that in mind when we look at the level of implementation.

I acknowledge the broad support, co-operation and balanced understanding always shown in this House in respect of these policies and the support for Sharing the Vision. Funding is essential. Budget 2022 provided €1.149 billion for mental health, including specific funding to enhance CAMHS. It allowed for the provision of two new CAMHS telehubs and a dedicated €6 million to expand capacity within the community mental health teams. Further investment was made last year in the national clinical mental health programmes and new models of care, many of which benefit young people directly. One example is the national clinical programme on eating disorders. An additional €1.15 million was secured enabling the development of three new specialist eating disorder teams, bringing the total number of teams funded to nine. There are four fully-operational teams now and the other five are nearing full recruitment, expecting to be fully operational early this year. It is a very important and welcome development that has come about because of the political prioritisation from the Minister of State. The CAMHS eating disorder teams are operational in community healthcare organisations, CHOs, 4 and 7 with recruitment well under way in CHOs 2 and 9.

Another programme was the CAMHS intellectual disability model of service, which the Minister of State, Deputy Butler, launched last September. It was developed to enhance services for those with intellectual disability, advancing the development of specialist mental health services and standardising the care. Currently, there are 38 mental health intellectual disability staff working across five CHOs. That work is ongoing and is very important. I know from talking to service users and parents, that pathway is not fully there many people. If there is a combination of mental health and intellectual disability issues, the model of care is meant to be very clear and laid out. However, it is not being properly or fully implemented in all areas, and it is something we are looking at.

Funding in 2022 also included €10 million for mental health services relating to Covid. Our service providers kept 90% of the services going during the Covid pandemic, which was good to see.

This year, the Minister of State secured an extra €57 million in core funding for mental health bringing the total budget to €1.2 billion. That is an increase of almost €200 million.

We need to promote quality and safety in light of increasing demand and case complexity. It includes more integrated care between CAMHS and primary care and disability services, which is so important. Yes, we need to focus on CAMHS. There are many excellent things happening in it but there are also many serious issues that have been identified in this and other reports. However, we really need to be talking about youth mental health, of which CAMHS is one part. We have primary care psychology and amazing community-based teams like Jigsaw and others and we need to maximise prevention, early intervention, low-complexity treatment where that is appropriate and make sure CAMHS is available for all those who need it. We are not there yet and because of that, there are referrals to CAMHS that would be better suited to fully functioning primary care psychology services and other community-based services as well.

However, an extra 500 people are working in mental health services since the Government took office. There is a workforce of 10,500 healthcare professionals and 97% of those roles are filled. The Minister of State is working with the HSE on the remaining 320. We have 73 CAMHS teams with clinical governance from 80 psychiatrists. Very substantial resources are in place.

The report is entirely on the money with regard to ICT systems. It is not good enough that community services across the country, not just mental health services, are still using paper files instead of IT systems. It is something we are prioritising and we need to roll that out quickly.

Two new roles are coming in to which the Minister of State will speak. One is a clinical leadership role while the other is an administrator of leadership role to make sure the changes that need to happen are championed and co-ordinated with broader healthcare supports in hospitals and the community.

I will finish where I started, which is by acknowledging the work of the Mental Health Commission and the very serious nature of the issues it has raised. They are issues the Minister of State sought to have raised. It is one important piece of work in several reviews that are ongoing to make we have the best possible services.

We get into very robust debates in this House, as we should. I was in the Seanad earlier. Some of the language used would lead one to believe there is not a nurse, doctor or health and social care professional in the country providing a decent service to any patient. Some of the language was around total systems failure, which we know is not true and it is not true of CAMHS either. A lot of people will be watching this debate. A total of 21,000 young people use CAMHS. Can we bear that in mind and bear in mind that the interim report explicitly states that many people are receiving excellent care and treatment as we discuss this over the next few hours?

4:44 pm

Photo of Mary ButlerMary Butler (Waterford, Fianna Fail)
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I thank the Minister for his contribution this evening and welcome all our NGO partners to the debate. I am very pleased to attend today with the Minister and I will also be in the Seanad next week.

The Government is fully committed to the delivery of high-quality, person-centred and recovery-oriented mental health services. The Mental Health Commission’s interim report on the independent review of the provision of CAMHS in the State by the Inspector of Mental Health Services looks at service delivery and administrative practices in five CHOs. The interim report, which focuses on five out of nine CHOs, is a timely contribution to the common objective of improving CAMHS overall, especially when it comes to quality and safety.

Following on from several meetings to discuss the Maskey report earlier in the year, I asked the Mental Health Commission to expand the remit of its annual thematic report to take cognisance of the Maskey report, which had been recently published. I was pleased to provide the necessary resources to the Mental Health Commission to enable this comprehensive review to take place running in parallel with the HSE national CAMHS audits. I look forward to the publication of the full report later this year and the relevant data supporting findings and I thank Dr. Susan Finnerty and her team for their work to date.

The Mental Health Commission plays a vital independent role in supporting and assisting in the development and improvement of mental health services. In highlighting areas where practices can and should be addressed, the interim report of the commission provides an opportunity to ensure that HSE services continue to be improved. At the outset, it is important to highlight that many of the findings in the interim report relate to specific operational issues within CAMHS teams that have been recognised and resolved by the HSE. However, young people and their families have the right to expect a service from CAMHS that is person-centred and meets their needs in a timely manner. Any single instance that falls short of the high standards that patients and their families should rightly expect is an area of concern. Like the Minister, I am acutely conscious of the 21,000 children and young people who receive supports from CAMHS. I am very conscious of the 770 people working in CAMHS who provide a very good service in the main. I was also very conscious when I spoke on radio this week on several occasions that the radio might be on in the waiting room and children and their parents might be listening to this debate. My job as Minister of State is to make sure we can put the correct procedures in place to make sure we can build confidence in CAMHS.

I am reassured from the ongoing and extensive engagement between my Department, the HSE and the commission regarding the findings of the interim report that care in individual cases has not been seriously compromised. Any areas of concern identified by the commission in carrying out its report were escalated immediately to the HSE for immediate action and resolution.

I understand the anxiety that patients and their families may have as a result of this interim report. Issues around open cases, medication reviews and governance of services are not to be taken lightly and I certainly do not take them lightly. It is of huge importance to me that parents are reassured that the services their children receive are safe and appropriate.

Last year, many young people and their families received excellent care and treatment within CAMHS teams, which have nearly 21,000 cases nationally and see 225,000 appointments annually. I again encourage anyone engaged with CAMHS to stay connected to his or her team. I have visited many CAMHS teams the length and breadth of the country in the past six months and was really struck by a young girl I met in Dundalk who came along with her mother. She had been in the care of CAMHS for four years, was almost 18 and was just exiting. She told me she had 96 appointments over four years. She had been seen every fortnight for four years. I was struck by her and how grateful she and her family were to the team for the help and support it gave her. There are many more. Notwithstanding that, we know there are many issues relating to not everyone receiving the service they should get.

As recommended by the commission, the HSE has confirmed to me that it is undertaking a review of open patient cases. This will initially consist of a review of all open cases where the patient has been prescribed medication by his or her CAMHS consultant or doctor and who has not been seen in the last six months by his or her CAMHS teams. This is the right thing to do. It is essential that these open cases are reviewed as a priority. I met with the HSE today and met with it yesterday with the Minister. We have had several meetings. This work will start immediately.

This review of open cases will provide crucial further assurances that these children and young people are receiving appropriate care that is reflective of their current and future health needs. Importantly, the review will include a focus on physical health monitoring for those who are on medication. As per the recommendation of the commission, these reviews will be based on NICE guidelines or similar relevant and clinically appropriate guidelines.

While this is an interim report with further work to be undertaken by the commission across the other four CHOs, the HSE has been proactive in ensuring that lessons learnt thus far have been disseminated throughout all CAMHS. On receipt of the draft report from the commission, the HSE national mental health office undertook engagement calls and meetings with all CHO management teams to share the observations and findings of the interim report.

All documentation in response to this report has also been shared with all CHOs, along with regular update meetings with heads of service and chief officers. In addition, lessons and recommendations from the Maskey report have also been shared with CHOs. At all times, the HSE has sought to ensure that it is proactively improving services based on the recommendations of reports and audits.

In the context of issues highlighted in the commission’s interim report, the new mental health Bill is at an advanced stage and will further underpin the rights of children accessing mental health services. It includes a number of reforms specific to children and young people such as the introduction of guiding principles; an overhauled approach to consent to admission and treatment for children and young people, including allowing young people aged 16 and 17 years to consent to mental health treatment on the same basis as physical health; and additional statutory safeguards such as the provision of information and care plans to all children and young people receiving inpatient treatment.

A new Part has been introduced to the Bill setting out the process of admission and consent to treatment for children, introducing capacity and consent for young people, and mirroring safeguards for adults under the Act for children, such as the right to information. The Bill will provide for the presumption of capacity for all young people aged 16 and 17 years to consent to mental health treatment. This will bring important parity between mental health and physical health on consent, as the Non-Fatal Offences Against the Person Act provides for people aged 16 and 17 years to consent to medical treatment.

The Government acknowledges that mental health services must constantly evolve and develop to ensure they are in line with international best practice and regulatory requirements. I note the recommendation from the commission regarding the need to regulate CAMHS. Regulations and standards play an important role in ensuring that healthcare services are safe, of high quality, and negate risk. Inpatient CAMHS are currently subject to the Mental Health Commission’s regulation, registration and inspection process, with annual inspections of each approved centre under the Mental Health Act 2001 (Approved Centres) Regulations 2006. As was set out in the published general scheme of the mental health Bill, the regulatory remit of the Mental Health Commission will expand to include all community residential services and all community services. Regulations will be drafted to set out the parameters of the commission’s regulation of these services following the enactment of the new mental health Bill.

Regulations must be drafted under relevant primary legislation, which in this case in the Mental Health Act. The new mental health Bill includes an overhauled approach to Part 5 of the Act which relates to regulation. As set out in the published general scheme, it will extend the commission's powers of regulation, registration and inspection to all community mental health services. The new Part 5 will provide a strong statutory basis to underpin the making of these regulations.

The significant and complex objective of drafting the new mental health Bill has been well under way for some time. I am pleased to say that the mental health Bill has been selected for priority drafting for the spring legislative session. Officials in my Department are working hard to progress the Bill with a view to the Bill being introduced as early as possible this year. The scale of extending the Mental Health Commission's regulatory remit to inspect all community residences and services will be sizeable and officials in my Department will continue to engage with the commission on both the drafting of these regulations and on the particulars of how the commission will take on the additional responsibilities. This, and any further recommendations for the Department arising from the commission’s independent review, will be considered on receipt of the Mental Health Commission's full report, which I understand will be completed by May of this year. Deputies will all be aware of the significant timeframes associated with finalising new primary legislation, and new regulations, and I know that I can rely on their support to expedite this as quickly as possible over this year, since this is important legislation.

An important new approach is that statutory entitlement to engage with an advocate will be included as one of the numerous proposed changes for the care and treatment of children in the Bill. This is grounded in a rights-based approach and belief that young people and their parents have the right to be listened to and consulted about their care, with meaningful participation and engagement that will assist their recovery.

In line with the current national policy, Sharing the Vision, HSE national mental health services is committed to further developing an advocacy service that will ensure service users are empowered to lead in their own care as is their human right. Advocacy services are currently available to all adult inpatient acute units provided by Peer Advocacy in Mental Health. While the need for independent advocacy services across CAMHS has always been present, the Maskey review has highlighted the need for independent advocacy services for both community and inpatient settings across the country. The youth advocacy programme, YAP, provides advice to young people and their families, and it plays a vital role in supporting them in their journey through CAMHS. I was pleased to launch this programme last August. It is operating in CAMHS in Galway, Linn Dara in Dublin and for CAMHS community services in Kerry. Further roll-out of this programme to the CAMHS units in Cork and north Dublin and to local community-based services is being progressed by the HSE.

The independent Maskey report of the review of care provided by south Kerry CAMHS made findings regarding significant failings across multiple levels of the system and made 35 recommendations to improve service delivery. These recommendations cover a broad range of areas such as re-establishing trust in CAMHS, governance of the service, delivery of clinical services, improved clinical practice and the use of information and communication technology to support the delivery of services. The Government and the HSE are committed to implementing the recommendations. The 35 recommendations have led to 63 actions, 19 of which, both national and local, have been implemented, with others under way.

Three specific audits are being carried out to provide assurance to those who use CAMHS. The HSE has commissioned independent national audits on prescribing practice, chaired by Dr. Colette Halpin, compliance with CAMHS operational guidelines, and research into service users' experiences of CAMHS. These audits will greatly help the potential for service improvement and expanding good practice. The information arising from the audits will be used to ensure that services meet the needs of patients and their families, and that services are provided to the highest of standards.

I turn to Kerry CAMHS and would like to outline developments. The consultant psychiatrist post at south Kerry CAMHS has been fully funded since 2016 but is unfortunately still vacant. The substantive consultant post has been advertised several times but is yet to be filled. Although extensive efforts to recruit to this post have been undertaken, the HSE does not envisage this post being filled in the short term due to a shortage of qualified personal applying in the area. Notwithstanding that, we have 80 consultant psychiatrists working across all 73 CAMHS teams. Extra clinical and administrative supports have been put in place at south Kerry CAMHS to support the team there.

As part of the implementation of the Maskey report and for completeness and good practice, a file identification exercise was initiated by the HSE in north Kerry to identify any remaining files where a doctor may have had an involvement, at any level. A screening exercise was carried out to establish what type of involvement the doctor had in each of these cases. From the screening process, a relatively small number of files was identified as requiring a full review. Dr. Maskey also undertook this review, which is now complete. The outcome of this review was that some children were identified as having an adverse outcome and some a minor event. The HSE commenced an open disclosure process on 14 December and offered to meet all the families involved. These cases fall within the same categories as the initial 240 identified by Dr. Maskey in the context of his original report.

I have fully supported the further reviews by the HSE into CAMHS in north Kerry. I am clearly concerned that 16 further cases have recently come to light in this area. I have been closely monitoring developments in this with the HSE and I am satisfied that appropriate action is being taken by the HSE. The HSE in CHO 4 will now establish a lookback review to focus on the files of young people currently under the care of the north Kerry team. The terms of the lookback review are being drawn up and the focus is on progressing this as quickly as possible.

In April last year, the Government approved a compensation scheme for individuals identified as affected by the Maskey report. This scheme is being administered by the State Claims Agency. Such a compensation scheme was called for by many mental health advocates, including families in south Kerry, and I was determined to drive this through to conclusion. I thank everyone who was here to listen to me and I will deal with other issues when I wrap up at the end.

4:54 pm

Photo of Mark WardMark Ward (Dublin Mid West, Sinn Fein)
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I acknowledge the Ceann Comhairle, the Sinn Féin whip, Deputy Pádraig Mac Lochlainn, the Minister and the Minister of State for agreeing to my request to have this important debate on the agenda today. I begin by thanking Dr. Susan Finnerty and the Mental Health Commission for this report. I welcome to the Gallery representatives from national mental health and children’s organisations, including ADHD Ireland, Shine, ISPCC, Mental Health Reform, A Lust for Life, Children's Rights Alliance, BelongTo and Pieta. I will have a number of questions throughout my speaking time that I ask the Minister to respond to in his closing remarks and if he is unable to, I would like a written response.

As we know, this interim report was published early because of the level of risk to children identified in CAMHS. Have the Minister, the Minister of State, the Department of Health or the HSE asked the Mental Health Commission to delay publishing of this report? If so, when did this happen and why was there a request to delay this report that had identified significant risks to children?

These risks were escalated to the HSE. When I asked the Minister of State, Deputy Butler, about the nature of these risks in December she told me that the HSE did not inform her what they were. When did the Minister of State become aware of the nature of these risks?

There is a huge disconnect between the Department of Health, the Minister and the Minister of State and the HSE. Where does this buck stop? Who is ultimately accountable and responsible for the current crisis in CAMHS? Nobody in a senior role in the HSE or the Department of Health was held accountable despite huge governance issues highlighted in the Maskey report.

Sinn Féin has been calling for the reinstatement of a national clinical director for mental health in the HSE. The role was discontinued in 2016. What was announced this evening is an assistant position. That is simply not good enough. The Minister of State has responsibility for mental health and her colleague is the Minister for Health. They must instruct the HSE to appoint a national director who will be accountable to her and responsible for mental health within the HSE. If I was Minister with responsibility for mental health that is what I would do.

I am going to provide some solutions. First, we need ring-fenced funding for CAMHS. It needs a clear and accountable budget. Sharing the Vision, the Government’s mental health plan, has not been costed and there is no timeframe for implementation. Sinn Féin set out a multi-annual funding plan in our alternative budget. The Government must do the same. That would give CAMHS the autonomy to put in place its own recruitment process that would not have to compete with other healthcare disciplines. The HSE needs to start doing comprehensive exit interviews with all staff who are leaving the service. That would to help identify the problems around staff retention and put measures in place to keep these vital workers in CAMHS.

As the Minister said, children need to move between primary care, disability services and specialist services, such as CAMHS, according to their changing needs. The never-ending waiting lists for children’s therapies are having an impact on children’s mental health. There are more than 13,000 children waiting on an appointment for primary care psychology. We have waiting lists for Jigsaw of up to 20 weeks. There are 4,000 children waiting on an initial appointment with CAMHS. That is an 86% increase in children waiting for vital mental healthcare under the Ministers' watch. I have spoken with families who are frustrated, distressed, and frightened as they try to cope with deteriorating mental health difficulties while left waiting. I am calling on the Minister to put in place a strategy to co-ordinate relationships between CAMHS, community disability network teams, primary care services and NGOs.

As we heard, the HSE is conducting three national audits into CAMHS. They cover the areas of prescribing practice, operational guidelines, and service user experience. Can the Ministers explain how there were no risks pertaining to CAMHS documented on the HSE risk register despite three ongoing audits? Are they aware of any risks to children identified so far by the three HSE audits?

The Mental Health Commission made repeated requests for an action plan for identified risks in the report. The plan, when finally received, was not sufficient to address the risks. In some areas reviewed, there was limited understanding as to what constituted a risk, how it was assessed and how it was escalated. Some CAMHS teams were so frustrated they did not bother to escalate risk as there was no point and that resulted in a haphazard reporting of risks. An urgent training programme on risk management must be rolled out to all staff at all grades in CAMHS.

I want the Minister to produce a report on the recommended minimum staffing levels in CAMHS. The last time this was done in any meaningful way was in A Vision for Change, 17 years ago. Education and training places must be rapidly increased across higher education to give us a pipeline for CAMHS staff. Children are presenting with more complex needs than ever before. The Minister must invest in early intervention for psychosis.

Staff are working beyond their contracted hours and are burnt out and frustrated. Staff in CAMHS go into this vocation because they want to help vulnerable children. As the Minister said earlier, some excellent treatment has been delivered by these staff in CAMHS. However, the report’s states that CAMHS depends heavily on a model of care which places the onus on a single profession, namely, the consultant psychiatrist. The report states that this is not in line with international best practice. Has the Government considered an alternative model of care?

One area the Government can put in place quickly is an integrated IT system. It is 2023. We should have that at this stage. Most services do not have an IT system that manages appointments and maintains clinical files. Only one CAMHS area had electronic records and these were provided through an independent agency. I understand that this is the St. John of God Hospital in CHO 6. The one CHO area that is operated independently from the HSE passed this review with flying colours. I think that says everything. What engagement has the Department of Health had with St. John of God to see how it manages risks, governance, and IT? That is a conversation that needs to happen.

From my previous career working with people who have addiction problems, I know the value of care plans. They are vital for a person’s recovery and personal growth. Care planning in CAMHS was either absent or of such poor quality to be meaningless. High quality care planning does not require extra resources and it is hard to understand why this was not taking place. This is another area with the proper training that could be resolved very quickly.

One of the most damming parts of the report was the evidence that some teams were not monitoring antipsychotic medication in accordance with international standards because there are no national standards at the moment. Some children were taking medication without appropriate blood tests and physical monitoring which are essential when on this medication. The Taoiseach acknowledged this in the House during the week.

It is of serious concern that in some CAMHS teams children with open cases were lost to follow-up. That means that children who should have had a review of prescriptions or monitoring of medication did not have an appointment for up to two years. That is downright scandalous. These included young people who had reached their 18th birthday with no planning, discharge or transition to adult services or any advice about medication. We need a plan for expanding CAMHS to help young adults up to the age of 25. This is international best practice, but currently we are letting children drop off a cliff edge at 18 years.

For one team, there had been 140 "lost" cases. This is a complete mess and children were put at unacceptable risks. Every resource possible must be put into finding these lost children and making sure an appropriate treatment plan is put in place. A complete clinical audit of every open case must be done as a matter of urgency. I know the Minister said this is going to happen. I would like to see a timeline on that clinical audit. The Government must set national standards for monitoring the use of antipsychotic medications by children and young people. That should be part of new regulations under the Mental Health Act focused on regulating CAMHS. It is clearly needed to ensure that no more children are given strong medication and then forgotten about. Can the Minister commit to implement this solution as soon as possible?

I am one Deputy with one member of staff and in less than ten minutes I have given the Minister and the Minister of State solutions to improve the quality of care in children’s mental health. There is no greater crime than denying a child the right to reach their full potential. Both of the Ministers have numerous staff, special advisers, a whole Department and the HSE at their disposal. Surely they can implement the solutions to keep our children safe. If they cannot do so, then it is time for someone else who has the ability, the strength, and the political will to address this crisis caused by their Government and successive Governments.

I will finish by acknowledging the work that staff in CAMHS do. I deal with them daily. They find the systems are working against them. Recruitment and retention and the panel system of recruitment needs to be looked at. It is something that can and should be done. It is delaying the processes.

How many of the 73 CAMHS teams which the Minister mentioned are in place are fully staffed? It has been stated that 97% of the time CAMHS responds to children in a couple of months. How many of them are responses that go to families to say it will be back in touch in a couple of months to give an appointment maybe this time next year? Some 600 children have been waiting for an initial assessment with CAMHS for over a year, which is not good enough. The Minister said that early intervention is key. We need to put things in place to ensure children get the care they need when and where they need it. A child who gets the early intervention is less likely to need more acute CAMHS care.

5:14 pm

Photo of Imelda MunsterImelda Munster (Louth, Sinn Fein)
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The Minister of State said earlier that it was important that parents are reassured that their children get the care and support they need. I start by retelling a nightmare story endured by a family over the past 11 days. It is one of hundreds of stories that have happened under the watch of the Government. It is a story about a father and his 16-year-old child. It started on Monday, 16 January when the parent received a call from the school that the child had attempted suicide by overdose. She was taken by ambulance to the accident and emergency department in Our Lady of Lourdes Hospital where she was admitted for treatment and given antidote medication. That was the fourth time this child had been admitted to hospital for the same reason.

On Wednesday, 18 January, Our Lady of Lourdes Hospital discharged the teenager with an appointment for CAMHS the next day, Thursday, 19 January. Our Lady of Lourdes Hospital indicated that no further treatment was needed. On the night of Wednesday, 18 January, the teenager self-harmed again. On Thursday, 19 January, at the CAMHS appointment, CAMHS advised she should be referred to a residential care facility but the doctors did not know when, where or if any place could take her. CAMHS felt that in the interim she was not safe at home and told her family to take her back to Our Lady of Lourdes Hospital. On Thursday, 19 January, the teenager was readmitted to Our Lady of Lourdes Hospital.

On Saturday, 21 January, a social worker at Our Lady of Lourdes Hospital tried to get her father to take his daughter home, saying that the hospital was not the right place for her. However, her father stood his ground and stayed there until Monday, 23 January. On the morning of Monday, 23 January, the father had to take his daughter to CAMHS for an appointment, but when he collected her from Our Lady of Lourdes Hospital the hospital had discharged her and advised him not to bring her back over concerns for her safety. They attended the CAMHS appointment where her referral for residential treatment was confirmed by the doctor but with no place, no date and no time.

On Monday, 23 January, her father, petrified for his daughter's safety, took her to Tallaght hospital where there is an adult psychiatric facility. He simply could not bring her home owing to concerns over her safety. For three nights the man and his teenage daughter were left sitting on a bench without even a pillow in a glass room with people walking by and staring in. The hospital advised it did not have a psychiatric bed for her and as she is an adolescent it could not admit her or give her a bed as she is deemed psychiatric and not medical. It is not the staff's fault. They were left in a room for three days and nights. The staff in Tallaght then liaised with the psychiatric doctors and eventually the teenager was told she would be admitted to St. Joseph's Hospital.

However, that only happened because of the staying power and strength of her father and the remarkable stance he took. It only happened because he went public with a plea for help. The Michael Reade show on LMFM highlighted their plight over consecutive days with the father telling shocked and appalled listeners what their family had to endure.

Here are the facts. There are no emergency places for adolescents in crisis in emergency departments. That is the Government's policy. No psychiatric beds are readily available for adolescents in crisis. That too is the Government's policy. How many teenagers do not make it because of Government policy? Hundreds need to go through this nightmare every day. That is the Government's policy. Parents are being told there are no psychiatric beds and no beds in emergency departments. Parents are told to take their child home and they are verbally given a home safety and care package. That is the Government' policy.

If families were to sue the HSE every time a child or adult presented in a mental health emergency and were refused adequate care or admittance, would the Government be quicker to change its policies? Can we imagine a person presenting with cardiac arrest and being told they could not be admitted because the hospital had no defibrillator, no trolley and no bed? Mental health care is just as important as general or physical care. The Government has treated it as the Cinderella of our broken health system for far too long.

I listened to both Ministers' opening statements. How can they sit there and listen to these stories that are happening every day? Time and again they listen to them. It is not as if this is the first time these issues have come to light and they still do nothing when they know full well that more families today, tomorrow and the day after need to live through the nightmare I described. Why is that? It is because it is the Government's policy. At what stage will it put those wrongs to right? For goodness' sake that is its job.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I agree with the Minister's comments about all the staff in CAMHS who do a wonderful job. However, let no Minister or politician hide behind staff in an attempt to avoid or dodge political responsibility for failures in the system. There are obvious capacity failures which have been identified for many years. This is not something that we learned about from this interim report. This echoes and reinforces what we already knew that capacity was not there. There have been governance issues in the system for many years and there was a failure to deliver. We cannot dodge political responsibility for all those failures.

In his opening statement, the Minister said that about 4,000 open cases will need to be reviewed. These are children who were prescribed medication and where a review or monitoring has not happened within six months. The obvious question is why was that not done beforehand. We now have a report telling us that this needs to be done but where is the capacity within the system for that to be done? Both Ministers said it will start shortly. How long will it take? Has the system the ability to do it? Has it the staff to do it? That question needs to be answered by both Ministers present. Why did it get to a point where we now need to review 4,000 cases? Why were those cases not dealt with before now? That is a clear failure. Somebody needs to take responsibility for that failure and it seems that nobody is.

The big challenge in healthcare across all settings is with workforce planning. The Minister talked about south Kerry CAMHS where we cannot recruit a consultant. There are many of examples in CAMHS where we cannot recruit staff to deliver the services that we need because we do not have a credible, comprehensive workforce planning strategy.

The Minister talked about youth mental health services. I think we need to develop a new child and youth mental health service that includes people from 18 to 25 years of age because far too many children once they reached the age of 18, reach a cliff edge and do not get the services they need. For many of them adult services are not appropriate and we need a serious realignment of that policy. Both Ministers will need to accept their fair share of the blame and responsibility for the clear failures identified in this report.

Photo of Thomas GouldThomas Gould (Cork North Central, Sinn Fein)
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We warned the Government that child and adolescent mental health services suffered during the Covid pandemic. We were given repeated commitments that efforts were being made, plans were being drafted, funds were being allocated and that the issue would be sorted. Things are now worse than ever before. There are 276 children in CH04 who have been waiting for more than 12 months. This is by far the largest number of children on waiting lists in the State.

Before Christmas, a constituent contacted me. She had to take her child to an accident and emergency department. She had been on a CAMHS waiting list for a long time. She was at serious risk of harming herself. She was discharged from the accident and emergency department with a letter for CAMHS. A week later still no letter had been received by CAMHS. The mother contacted me because she was distraught worrying about her daughter. I had to contact the HSE and everyone I could get on to.

Within an hour, we got that letter so that CAMHS could see that young girl. A Deputy should not have to send emails and make phone calls to everyone when it comes to life-saving treatment a child or adolescent needs. This is not a CAMHS issue alone. This goes to the whole issue of the crisis in the health service.

I also raise the issue of the Psychiatric Nurses Association and the statement it put out this week. The Minister is probably well aware of that statement, which referred to staffing levels in Eist Linn in Cork. It is a 16-bed unit, the only one in the southern region. I am hearing through the grapevine that Eist Linn is losing a significant number of staff. In the next few weeks, staffing levels will be only 58% of what they should be. Some of the staff are going to Australia because they will be better paid, better treated and will be able to access housing. This goes to the nub of staff retention, a point on which my colleague, Deputy Cullinane, touched. The Government is completely failing to enable access. That is the reality faced by children and adolescents in the mental health sector. The staff, children and their parents need to know what is happening in Eist Linn. Will the Minister give us an update on the proposed plans for the facility? Will he guarantee that no beds will be lost in that unit?

The Minister said earlier that he empathises. Parents of children and adolescents with mental health issues do not need empathy. They need help and support. I am asking the Minister to guarantee that none of those beds will be lost.

5:24 pm

Photo of Duncan SmithDuncan Smith (Dublin Fingal, Labour)
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The interim report of the Mental Health Commission on CAMHS is one of the most damning reports to have been presented to a government in living memory. There has been discussion of the issue this week, including this evening. The presence of both the Minister and the Minister of State, Deputy Butler, is testament to the issue's importance. It is often the case that evening debates on a Thursday in this Chamber will not attract the presence of the senior Minister, whatever the topic under discussion. The senior Minister is here, along with the Minister of State with responsibility for mental health, because this report is one of the most damning we have seen.

Even on a scan of the report, the key words that occur to the reader are "frightening", "negative", "worrying" and "damning". When one reads the report in detail, there is little to provide any comfort that our CAMHS is not broken. The report states that some CAMHS staff have been found, in some cases, to provide a good service for many young people and their families, who have received excellent care and treatment within often limited resources. That is mentioned at the start of the report and it is accepted. We all know people who have been treated in CAMHS and families who have received a good service. However, the report goes on to deliver its assessment of the community healthcare organisations, CHOs, it examined. It begins with governance, which it describes as "inefficient and unsafe". The report identified a failure to manage risk or fund staff, which is a departmental and HSE issue. It identified a failure to recruit key staff and a failure to look for alternative models to provide services where staff could not be recruited. That shows an inflexibility throughout our health service. We see that reflected in Kerry CAMHS, where a funded position has been in place but not filled since 2016. The statement made earlier by the Minister of State, Deputy Butler, indicates that position will not be filled in the near future. The report also identified a "failure to provide a standardised service across and within CHOs". Even if a CHO is performing well relative to other CHOs, there may still be CAMHS services in the area that are not performing well. The report goes on to state "There is no ring-fenced funding for CAMHS". It is incredible that CAMHS must fight for funding and compete for it with other health services.

Underpinning all of this is early intervention. Such intervention with multidisciplinary teams will help to keep people healthy, safe and out of acute care, ultimately saving the health service time, money and resources. At the earliest point in people's lives when they face mental health difficulties, we have a service that is competing with other health services for basic funding. We have no real integration in children's mental health services and risk management is obliterated in our CAMHS.

The report identified that "risk management was poor, with lack of communication and lack of actions to mitigate risks". It stated "There was limited understanding in a number of teams as to what constituted a risk". That is incredible. Teams that are working do not even know what constitutes a risk. That is why this report is damning. The documenting of risks was described in the report as "haphazard". Individuals and families put trust in our health service, specifically our youth mental health service, and have to read a report that describes the documenting of risks as "haphazard". The report went on to state that "minimalist generalised actions [were] recorded on the CHO risk register".

All teams were found to be significantly below the staffing levels recommended in A Vision for Change. Some were below 50% of the recommended level and all teams were below the recommended level. That has resulted in the long waiting lists we have all heard about in the responses to multiple parliamentary questions. Those waiting lists have been discussed on the floor of the House many times.

The report states "The CAMH service depends heavily on a model of care which places the onus on a single profession i.e., the consultant psychiatrist". That takes us back to the situation in south Kerry and the presentation from the Minister of State, Deputy Butler. This inflexible system cannot change or provide a different model of care and cannot recruit key positions, including the one key position of consultant psychiatrist. That means care for everyone else falls down.

The report also states, "In three CHOs, the digital infrastructure was mostly absent apart from the use of Excel spreadsheets and Word documents." If somebody contacts the offices of any of the Deputies here today, we have a system to record the representation, raise the matter with the relevant Department, the HSE or CAMHS. Our system allows us to set reminders and schedule when to send further emails and letters. We have such a system. It is an old system but it is functional and works. In our health services, according to the report, "Most services do not have an IT system that manages appointments, schedules rotas, maintains clinical files and provides reports on activity." If someone sends a Deputy a report from an occupational therapist or a doctor, he or she can scan it and save it on our systems while the HSE and CAMHS cannot do so because they have no IT system. That is incredible. No one would believe that our health services are dealing with Excel spreadsheets and Word documents. Every eight-, nine- and ten-year-old who goes into his or her first ever computer class learns to use Excel spreadsheets and Word documents. The system in this organisation is more than 30 years old but still functions. We do not even have something of that age and functionality in our CAMHS.

I will move to the issue of medication and the fact that children are being lost to antipsychotic medication without clinical and physical backup. That is incredible and very worrying. Specific medications are not mentioned in the report but we all know which are the most commonly used medications. They have side effects and require regular blood testing. There are international standards but we do not have national standards, and the international standards are not being applied. Not even good, basic care is being applied to these young people who are on very heavy drugs. We have two generations of antipsychotic drugs. There are traditional ones and the newer ones from the 1990s. They are all very heavy and have considerable impacts, including physical impacts, on patients. Young people are being lost. They are being prescribed these medications and are not being given check-ups.

It is an absolute scandal. We need action to ensure that a proper audit is done and that there is no child or adolescent out there who is on anti-psychotic medication and who is not getting the required supportive clinical care, be that blood tests or physical checks. In regard to the mental health reform, it has been doing great work in advocating in this area and supporting Deputies on all sides in providing information. Its key ask is a youth mental health assistant director, which was promised in budget 2023 but has not even been advertised for recruitment. We need a national director for mental health. Why is that not being provided to report directly to the CEO of the HSE? The Government is moving in this direction but is not going far enough. If we are talking about governance we need a co-ordinated strategy at national level. That starts at the very top if we are serious about resolving this and not having this same debate when the full report comes out. In fairness, a reform of the Mental Health Act was mentioned by the Minister of State, Deputy Butler, in her contribution.

There were 140 children lost in the midwest CAMHS system and 46 children in south Kerry suffered significant harm. There are unknown numbers of children and adolescents on heavy medication without the appropriate care. We have seen articles in newspapers this week about individual cases. I met a woman at a local event yesterday whose child is on attention deficit hyperactivity disorder, ADHD, therapies through CAMHS is getting the care but her worry is that next year, she will age out of the service. There is no pathway. There is no ADHD clinical specialist in our CHO. She will age out of the service three months before her leaving certificate examinations, when she turns 18. What is going to be done there? The individual cases will go on and on but as was said by the CEO of the Irish Society for the Prevention of Cruelty to Children, ISPCC, in a letter to The Irish Times, the system "is broken”. That is the only way to describe it.

5:34 pm

Photo of Christopher O'SullivanChristopher O'Sullivan (Cork South West, Fianna Fail)
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I welcome this opportunity to talk about CAMHS in CHO 4 in particular, which covers west Cork, including my constituency. There is clearly an issue there. The findings of the report are damning, especially in the Kerry area. My heart goes out to the families and the children who have been impacted by this. As has been brought to light recently, there is a mental health unit in CHO 4 in Bantry General Hospital which recently has been forced to close from an 18-bed unit down to a 15-bed unit. Reducing to a 15-bed unit in the midst of huge pressure on the services, huge need for extra mental health services, is not good news by any stretch of the imagination. The HSE challenged the recommendation of the Mental Health Commission to reduce it to 11 beds so it could have been much worse. However, it certainly underlines the urgent need for a specifically purpose-built facility to cover that area of west Cork. That is vital. The Minister of State, Deputy Butler, is aware of it, I brought it to her attention at the very start. While we have lost three beds it is important that we see the investment that was promised in the agreement outside of court to bring it back up to an 18-bed unit in the interim because the services are very stretched. CAMHS in west Cork constantly looks for extra services. It has a facility in Dunmanway in which to meet young people. We need to expand the services in Clonakilty. The Minister of State visited Clonakilty hospital as well and heard that plea.

There is a similar theme happening here. Earlier this week I spoke with the Minister of State, Deputy Butler, about the provision of home support services. There is a theme whereby the Minister of State, Deputy Butler, and the Minister, Deputy Stephen Donnelly, have secured record amounts of funding for the health service. It was an increase of 40% from €16 billion in 2019 to €23 billion throughout the service, as well as €1.2 billion for mental health. These are record amounts of funding and finance going into mental health. However, the HSE needs to be held accountable. We need to get value for money. We need to see a return on this investment.

In the time I have left I want to bring up another issue which is related to the mental health of women and pregnant women. Yesterday, I brought to the attention of the Minister, Deputy Donnelly, the issue of hyperemesis and the difficulty in accessing the treatment for hyperemesis, Cariban. Hyperemesis is a debilitating condition whereby women in pregnancy experience severe nausea, vomiting and loss of the ability to function because of the extremity of the nausea. Over the past 24 hours since a campaign started on this, I have been contacted by hundreds of women throughout the country who have brought their experiences to my attention. I want to take this opportunity to thank each of those women who shared personal, intimate and sometimes graphic experiences of what they have been through. It is important that I do them justice and take this opportunity because I may not get an opportunity to speak on health again in the coming weeks. It is important that I take this opportunity to raise their concerns and give examples of what these women have had to go through.

Some women who contacted me went through pregnancy where on some days, they vomited up to 50 or 60 times a day. I cannot even begin to imagine what that must be like. In some instances it was so severe that they experienced nosebleeds or the dehydration was so bad they had to be connected to intravenous drips to battle the dehydration. Coming back to the mental health issue, in many cases it increased the chance of post-natal depression. Many women who contacted me spoke about that. It reduced their ability to function, to go to work and in the worst cases they had to be hospitalised. That is how serious it is. One woman said it was so severe that even though they intended to try for another child she could not go through it again, so they did not.

I wanted to give a flavour of what women are experiencing when they have hyperemesis. There is a treatment, a drug called Cariban. It works. It eases the symptoms but it costs money. For example, one lady who contacted me spent €6,000 on Cariban over the course of two pregnancies. Another lady paid €3,000 over the course of her recent pregnancy. This is a great deal of money for something that should be affordable and accessible for all women. Other figures were €140 per week. Many of these women were experiencing financial difficulty anyway. They may have had mortgage repayments or rent to pay. One woman who contacted me described the situation where she had to choose between the weekly shop or a course of Cariban. It is a serious condition and it requires treatment.

What is the issue? Thankfully the Minister, Deputy Donnelly, listened and in budget 2023 secured agreement that Cariban would be covered under the drug payments scheme. This is an important move. It was welcomed throughout the country especially by those people who were campaigning for this. The difficulty is, it emerged in January, that while the drug can be prescribed by a GP, it was only available for reimbursement under the drug payments scheme if it was prescribed by a consultant obstetrician. That is one of the issues. When the consultant obstetrician is prescribing this drug there has to be a manual filling out of a form which has to be scanned and then may take days to get a response. It is cumbersome and takes too long while these women are going through this experience.

Photo of Verona MurphyVerona Murphy (Wexford, Independent)
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To be fair, Deputy O'Sullivan, this session is on mental health.

Photo of Christopher O'SullivanChristopher O'Sullivan (Cork South West, Fianna Fail)
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It is mental health. It is a really important issue and this may be the last chance I have to bring it up.

Photo of Verona MurphyVerona Murphy (Wexford, Independent)
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I think you should write to the Minister. I will give you a little bit of latitude but to be fair to everybody-----

Photo of Christopher O'SullivanChristopher O'Sullivan (Cork South West, Fianna Fail)
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I will wrap up in a couple of minutes but it is related to women's mental health issues. It is very important that it is aired here.

Photo of Verona MurphyVerona Murphy (Wexford, Independent)
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I appreciate that; I am not minimising it, I am just saying that-----

Photo of Christopher O'SullivanChristopher O'Sullivan (Cork South West, Fianna Fail)
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I am not trying to take away from the greater issue of the child and adolescent mental health service which I touched on as well.

Photo of Verona MurphyVerona Murphy (Wexford, Independent)
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Photo of Christopher O'SullivanChristopher O'Sullivan (Cork South West, Fianna Fail)
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What needs to happen is, there are drugs like Cariban that are not registered and which GPs can prescribe and they can be available under the drug reimbursement scheme. It happens with such drugs as Utrogestan and Androcur.

We need to introduce emergency measures that will allow GPs to prescribe Cariban, as they already can, but then allow these women to be reimbursed for it under the drugs payment scheme. The women now impacted by this deserve it, their families deserve it, and it is the least we can do to help them. I look forward to hearing the response from the Minister.

5:44 pm

Photo of Verona MurphyVerona Murphy (Wexford, Independent)
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We move to Sinn Féin. I call Deputy Réada Cronin, who is sharing time with Deputy Pat Buckley.

Photo of Réada CroninRéada Cronin (Kildare North, Sinn Fein)
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Before I come to the issue in question, which is the report on the child and adolescent mental health services, CAMHS, if we are having a debate about hyperemesis gravidarum, I could take part in that as well, having suffered it myself and having been hospitalised with it.

To get back to this issue, we are a small State that pays its department heads and health managers handsomely, so the very idea that CAMHS is in the state it is in is a damning indictment of that management and the Ministers. The very idea that in one CHO alone we have 140 children described as “lost” within the system is staggering and should have all the alarm bells ringing. Has it not dawned on all this management in the HSE that medicine in any area, especially mental health, is not a numbers and management game but a game that involves having the right people with the right expertise?

My blood ran cold when I heard a young doctor talk last year about simply being a person who was rostered in to fill a job in mental health when his training and experience was minimal. It ran even colder when the person said they were left doing that job in mental health without adequate support or supervision. I felt sorry for this doctor. I cannot imagine the stress of being in that position, feeling that you are just a number looking after other numbers. Is it any wonder that the invisible wounds in our children are being missed when they are being treated by doctors who are not qualified in the sense of experience, practice and area interest? I doubt very much that the same well-paid management would put a junior respiratory doctor in charge of amputating a leg or removing a gallbladder, but when it comes to the mental health of our children and young people, it seems that anything goes. That is why my heart goes out to the trained teams who have the expertise and the practice, and who are having to work way beyond their hours and limits, but do so anyway because they are committed to the care of our young people. We are very lucky to have them.

The Minister must do as the inspectorate recommends and review all cases currently open within CAMHS, focusing especially on children lost to follow-up and looking at children on antipsychotic medications. We have to put the regulation of CAMHS under the Mental Health Act 2001. The Minister started his speech by saying the current figures are unacceptable. When we say something is unacceptable, that should mean we do not accept it. Please do not tell us about lessons being learned because our fragile children are living them, and they are the ones who have to accept these failures.

Photo of Pat BuckleyPat Buckley (Cork East, Sinn Fein)
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I will go straight to the punch. The following quotes appeared in a media report, and I thank Dr. Susan Finnerty of the Mental Health Commission for her contribution to that. The report states:

A deep dive into mental health services for children and young people in Ireland has shown several regions in the south - including Cork - to be facing very serious issues that could be placing kids at risk. ... A failure of management and governance was leading to what the report called "inefficient and unsafe” CAMHS services and there were specific instances of very worrying dysfunction - such as evidence that anti-psychotic drugs were being given without proper supervision or monitoring.

The report goes on to identify several other issues:

Children getting 'lost' in the system with families facing a maze of bureaucracy in their search for help

Long waiting lists

Staffing problems

Lack of capacity

Lack of emergency and out-of-hours services

Failure to manage risk

Failure to properly resource services or support staff

Ironically, Deputy Butler is the third Minister of State with responsibility for mental health in the short time I have been in the House. I sit on the Committee on Mental Health. I remember talking to a child psychologist who was involved in CAMHS and who came as a witness to the committee. The first question I asked that gentleman was whether he had been threatened by senior management not to come in as a witness, and he said “Yes”. There is a dysfunction within the HSE and it is rotten to the core.

One of the speakers mentioned Bantry Hospital. We are talking about mental health yet we are still closing a 22-bed mental health respite centre, the Owenacurra Centre in Midleton, and I want to put that on the record. I have also been informed that Cork is lacking and is probably 20 to 30 years behind the rest of the country. The Minister spoke about value for money. Back in 2018, we spent about €40 million on cognitive and other therapies but we are spending more than €400 million on medicine, so there is a massive overreliance on medication for people. It is disgusting when we find young children on one of the strongest medicines in the world. It is crazy.

Although we are discussing this in the House now, an hour ago, Róisín Clarke of Mental Health Reform pointed out that we are still going to admit children to adult wards, which is in contravention of the child's human rights. This is 2023. I appeal to the Minister to take everything on board. I am here a while. I have lost faith in the mental health system in this country, but not in the staff.

Photo of Verona MurphyVerona Murphy (Wexford, Independent)
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I call Deputy Gary Gannon.

Photo of Gary GannonGary Gannon (Dublin Central, Social Democrats)
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I cannot help but despair when listening to this debate. It is a year to the day since the publication of the Maskey review into South Kerry CAMHS and the situation remains dire. Vulnerable children are being utterly failed on this Government's watch and the Minister’s colleagues’ chorus of concern is of little help. I note in particular that the Taoiseach and Tánaiste described the report as "concerning" and "unacceptable". I would agree, but it is almost like they are surprised. We would be forgiven for forgetting that both are former Ministers for Health.

This Government is just playing to the gallery. They have known about this crisis for years. How many more children have to suffer because of Government inaction, which the Minister today described as “unacceptable”? How many more reports do they need before they take meaningful action? This is a service which treats some of the most vulnerable children in our society but it remains poorly resourced. It is a postcode lottery, and if you find yourself in the wrong CHO area, your child could languish on a waiting list for months, even years, or become one of those "lost" cases.

Is there a more harrowing description than a “lost” case? These "lost" cases were cited in this week's damning report and they are particularly concerning. These are children and young adults with open cases who have been lost to follow-up. In some cases, children who should have had follow-up appointments for review of prescriptions or monitoring of medication did not have an appointment for two years. As if that was not bad enough, we also know that when some young people reach their 18th birthday, even if they have not completed the leaving certificate, they simply fall off a cliff. There is no planning, no discharge and no transition to adult services, and no advice about medication, simply abandonment.

This brings me to a related issue which impacts the whole health service but the crisis in CAMHS has brought it into sharp focus. That is our IT infrastructure, or the lack thereof. Yesterday, officials from the Department of Health appeared before the Committee on Health regarding electronic records, and they did not inspire much confidence. The e-heaIth strategy is now eight years old yet we heard that the project is "only at the starting line". That is scandalous. How are we still talking about starting lines eight years later? Why are we so far off course? We will never make progress on integrated care without the implementation of electronic records. In fact, why are we talking about the implementation of electronic records in 2023?

The Government’s failure to modernise our IT infrastructure has major implications for CAMHS. The interim report revealed that four out of the five CHOs visited used paper-based files. The report said these paper-based clinical files were frequently disordered, incomplete, sometimes illegible and devoid of logical filing systems. In 2023, it is completely unacceptable that most CAMHS teams are still reliant on paper and pen. Aside from making us an outlier internationally and a joke by any sort of modern metric, this outdated system of filing makes it difficult, if not impossible, to follow the care and treatment pathways delivered by CAMHS. This may seem like a peripheral issue in the grand scheme of things but it is at the very heart of the problem.

Another factor in this crisis is a lack of accountability and local decision making. The centralised nature of the HSE is totally flawed. When scandals come to light, everyone is to blame but, most importantly, nobody is held responsible. Last year, we learned that a junior doctor was effectively running CAMHS on his own in south Kerry, with little or no supervision. That junior doctor should not have been scapegoated for the entire scandal. There has to be accountability for this stunning failure of the senior management and those with ministerial responsibility, but without serious restructuring of the HSE, that will never happen.

We are still waiting for the Minister for Health to implement the new regional HSE structures mandated by Sláintecare. Under those reformed structures, there would be legally enforceable accountability among senior management teams for failures in clinical care.

This radical restructuring will completely shift the balance of power in the HSE, devolving power to local regional bodies. Aside from the clear benefits in accountability, it will provide for more patient-focused services and improved health outcomes, something desperately needed not just in CAMHS but across the entire health service. This is a key recommendation in the Sláintecare report but, like so much of the plan, implementation is proceeding at a snail’s pace or still at the starting line. As we have seen with countless reports, it is a case of all talk and no follow-through.

It is 17 years since A Vision for Change was published. This report detailed a number of deficiencies in youth mental health services, yet the system remains in disarray. As matters stand, staffing equates to just 56% of what was outlined under A Vision for Change guidance on staffing levels. That is a shameful indictment of successive Governments. This chronic understaffing of CAMHS is having a detrimental impact on the mental health of so many children. It is time the Government stopped wringing its hands about dysfunction in CAMHS and did something about it.

As well as seriously scaling up recruitment, the Department and HSE need to engage in proper workforce planning and move away from centralised recruitment. Due to this model, local services have serious difficulty hiring the staff they need at the time they need them. These measures should have been taken years ago. I urge the Minister to immediately progress them to address this historical and horrific understaffing.

While I welcome the announcement that a national clinical lead for youth mental health will be appointed, this process, which was promised in budget 2023, must be a prioritised. It essential that the recruitment process beings immediately. However, this is not the only new appointment needed. There has been no national director for mental health since 2016. The Government committed to reinstating this post in the programme for Government but I have yet to see proof of any progress beyond that.

Ultimately, we need to know that the Minister has the political will to overhaul mental health services. Behind every CAMHS waiting list figure is a child in need and a child who is being left behind. Almost 600 children were waiting over a year for a CAMHS appointment last November, an increase of 168% since June 2020. I appreciate that Covid-19 has exacerbated the problem but the need is great and the will must match it. We should be treating mental health just like physical health and not allowing conditions to worsen to a point where emergency interventions are needed more often. On every level it makes sense to fund these services.

This chronic under-investment cannot continue. Our piecemeal system needs root and branch reform because too many children are falling between the cracks. This resistance to change has to stop. The children who are being failed by CAMHS will not get their childhoods back. The Mental Health Commission's report may have been interim but the Minister’s response must be immediate.

5:54 pm

Photo of Marc Ó CathasaighMarc Ó Cathasaigh (Waterford, Green Party)
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In common with probably every Deputy in the House, I have a reading list as long as my arm and I wish I had more time to devote to reading what comes across my desk every day. While this report does not strictly fall within my bailiwick as a party spokesperson, I felt compelled to read it. When I started reading the report I had to get to the end of it and having read through it, I felt compelled to speak on it. If it is a difficult read for me, I can only imagine how difficult it is to read for somebody who is working in CAMHS and experiencing the burnout referred to in the report and being burdened with overwork. I can only imagine how it must be to read it as the parent of a child who is struggling to access services.

I note that Mental Health Reform in its briefing note, for which I am very grateful, described the Mental Health Commission’s interim report into CAMHS as a damning indictment of a deepening crisis in our mental health services. It is difficult to read the report in any other way. I acknowledge the Minister's comment that the contents of the report are unacceptable.

Article 24 of the UN Convention on the Rights of the Child, which we ratified in 1992, states that all children have the right to enjoy the highest attainable standard of physical and mental health. We often hear trotted out on the floor of Dáil a famous line from the 1916 Proclamation which commits us to cherish “all the children of the nation equally”. Are we living up to the standard of that foundational document set out over a century ago?

We are seeing in this report that children with mental health difficulties are essentially prisoners of geography unless their parents have the means to transcend that geography and step outside the public system. The Minister was careful to say that we have to acknowledge that much of the care received by children in CAMHS is very good, and that is also acknowledged in the report. However, it should not be the case that the standard of care received should depend on where people live or how deep their pockets are. That is not vindicating our commitment under Article 24 or cherishing all of the children of the nation equally.

As I said, the report makes for difficult reading and demands a Government response. The Minister and the Minister of State, Deputy Butler, set out in detail some of what is being done to tackle the issue. I also acknowledge that the report is a result of research commissioned by the Minister of State, Deputy Butler, to get a better understanding of what we need to do. The very fact that the Inspector of Mental Health Services, Dr. Susan Finnerty, felt she had to issue an interim report is a measure of how seriously and urgently she views the situation.

As I said, it is important to acknowledge the work of the 770 people who are working in CAMHS and how difficult this report must have been for them to read. I know each and every one of them strives to provide the best possible service to the people in his or her care. It must feel like the task of Sisyphus for them every day when they go back into work and the boulder, again, is at the bottom of the hill.

I also acknowledge that 21,000 children are accessing CAMHS and also Dr. Finnerty's explicit statement that, for the most part, the quality of care received by those children is excellent. That is also important. We must highlight the deficiencies and prioritise those areas in which we can drive improvement but we should depict the service as a complete failure. That would not be an accurate picture.

The Government and Oireachtas have an obligation not just to identify the problem but to begin to set out solutions as we see them. As Deputy Gannon and other Deputies noted, we have to look at workforce planning and benchmark the staffing levels we require within CAMHS. We know this cannot be solved immediately but we need to do so in the medium term. There is a role for the Department of Further and Higher Education, Research, Innovation and Science in ensuring we deliver the people who will fill those roles into the future. We need to recruit more people into CAMHS.

On a related matter, we also have the children's disability network teams, CDNTs, in which there is also a major issue with recruitment. That is also part of the picture. Services must connect better and I include primary care in that picture. It, too, is identified in the report. We have to ensure the communications between the different strands of the health system are better connected and speak to each other. As we know, that will take time but we can refine that planning now.

Dr. Finnerty pointed out that there is no ring-fenced funding for CAMHS. With regard to my earlier point about workforce planning, unless we have a ring-fenced budget and benchmarked staffing levels, I am not sure how we can engage in workforce planning. Perhaps the HSE can address that.

I also mentioned that the integration of children’s mental health services is not where it should be. We need CAMHS to talk to the CDNTs, primary care and GPs for the benefit of the child. Services should be child-centred and follow the person and we need to ensure communication streams are better. On digital infrastructure, it should not be the case, as highlighted in the report, that some records are held in physical format, with pieces of paper often added as the file is developing.

The type of recordkeeping for CAMHS that exists in each of the CHOs has to to streamlined and standardised. It should be the same across all our CAMHS. That is something Government focus can help resolve.

Deputy Gannon referred to the wider matter of the digitalisation of health records, which was discussed at the Oireachtas Joint Committee on Health yesterday. Let us expedite that. The Chief Whip is present. I know the health information Bill is priority legislation. Let us make that happen so that, for example, somebody's PPS number can be used to hang health records onto in order that digitisation can begin in a meaningful way. Procurement is a matter that the Minister of State at the Department of Public Expenditure and Reform, Deputy Ossian Smyth, might look at. If there is no standardised approach to the digitisation of records across CHOs, should the State not enter into a process of consultation with the CHOs, ask them what they need from the digitisation of records, go ahead and procure that, provide it to them, provide the necessary training and make sure there is consistency across the board?

On the supervision of medication, which was referenced by some Deputies, there is a network of pharmacists. Is there a role these people can play in the supervision of medication? They are highly trained, competent, and the network exists within our communities. Is that something that can be activated in response to this issue?

I would not claim to be any sort of specialist on this matter. The Minister and his Department are far closer to it. As I mentioned, it commissioned research to better understand the picture in front of us. I am responding to this issue as a parent and in empathy with the parents who have to navigate that torturous and labyrinthine pathway to getting the mental health supports they need for their children. If you are a parent, and your child is struggling and you reach out to the State for help, it is so important that the State is there. We have to live up to that obligation. As I said, this is something we have committed to in ratifying the UN Convention on the Rights of the Child in 1992. This matter sits at the heart of that cornerstone document and the foundation of our State. It is something I feel strongly about. The Minister and the Ministers of State have outlined the many ways this Government intends to respond to this report. It is incumbent on all of us to engage with that so we push that agenda forward in a constructive manner for the good of all the children in the State.

6:04 pm

Photo of Claire KerraneClaire Kerrane (Roscommon-Galway, Sinn Fein)
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It is an appalling indictment to think that in 2023 so many children are in need of support throughout the State. This includes various levels of support, whether it is therapy or supports through CAMHS. They are being so severely failed. Of course, this is not a new issue. In my constituency, there are 247 children in CHO 2 across counties Roscommon, Galway and Mayo who are all on CAMHS waiting lists. These are children, who are very young in some cases, whose childhoods are being destroyed. Parents, in particular, loved ones and, in fact, the entire family are left to beg for support and services, and to feel helpless, as they watch their child or children struggle.

The question of how seriously this issue is being taken by the Government has to be asked. I saw a prime example of this in my constituency shortly after I was elected. The e-mental health hub in Castlerea was opened in June 2020 to great fanfare. It was a wonderful facility for older people but it was closed. They were sent here, there and everywhere away from their families. These were older people with dementia. Money was spent on the building and it was done up. In 2021, following many questions, I discovered no funding had been provided in 2021 to staff the facility. It was a fancy, done-up, empty building. That continued until funding was eventually announced late in 2021 after I repeatedly raised the issue. That service is now in place and is at long last fully staffed, which is welcome and will make a difference. That is what we are seeing on the ground. It is why I question how seriously this issue is being taken, when the State puts money into a facility and then does not bother to pay to staff it.

This report is frightening. It is a lot more frightening for those people who are affected by the issue, especially those on waiting lists. Children on waiting lists are being failed across the board. I looked at the waiting lists for psychologist appointments in counties Roscommon and Galway. Some 804 children are waiting. Of the 702 children on the County Galway waiting list, more than half are waiting more than a year. It is an incredibly appalling situation. Everything possible needs to be done to turn this around and get these children the supports they so desperately need and that they deserve.

Photo of Maurice QuinlivanMaurice Quinlivan (Limerick City, Sinn Fein)
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The Mental Health Commission report is yet another indictment of the state of medical services, particularly mental health services in the mid-west region. Our major hospital is in a perpetual state of crisis and our mental health services are not functioning as they should. Last week, in Limerick, thousands of people marched in protest at the conditions in University Hospital Limerick. We now see those young people who are suffering mental health challenges are not receiving the supervised treatment they need.

The Mental Health Commission report outlines familiar failings, such as the lack of staffing and capacity. Mental Health Reform notes there were more than 700 mental health staff vacancies. The author outlined five areas of particular concern, including a lack of staff and a high staff turnover; lack of capacity to provide needs-based therapeutic programmes; poor monitoring of medication; lack of clinical governance; and long waiting lists that are impacting on the safety and well-being of children. Mental health is as important as physical health. To see such concerns raised about the treatment of children and adolescents must be treated as a major concern, both by the Minister of State with responsibility for mental health and the Minister.

I received a call from a HSE staff member the other night, who was upset about the terminology used in the report. This person did not express any upset about what happened. They were upset that the phrase "lost children" was used. In my constituency of Limerick, I understand 140 children are defined as being lost in the system, although the HSE was more concerned about the use of the term "lost children" than sorting out those children's situation. I urge the Minister to ensure that those children are found. They are not lost but each of them is somebody's child. Some of them were on medication and not having a follow-up for two years is outrageous. It is inexcusable that some children on anti-psychotic medication were not properly monitored.

Whatever way the Minister or the HSE frames it, this report is damning. It is a damning indictment of our mental health services, a damning insight into how we treat children at risk of mental health challenges, and damning evidence that the Government does not treat mental health issues with the urgency they need. The report's author, Dr. Susan Finnerty, put it aptly when she said the commission decided to issue an interim report because of the serious concerns about, and consequent risks for, some patients that were found across CAMHS areas 4 and 5.

My time is running out so I will try to get in as much as I can. In January 2023, 138 people in one CHO area were waiting more than a year. That is young children waiting more than a year for treatment out of a total of 423-----

Photo of Verona MurphyVerona Murphy (Wexford, Independent)
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The Deputy can follow up through email.

Photo of Maurice QuinlivanMaurice Quinlivan (Limerick City, Sinn Fein)
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-----so I would appreciate action on this.

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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I welcome this debate and the Mental Health Commission's interim report. It makes for very stark reading, to say the least. The issue of no clinical oversight is at the heart of the report. That is what it comes down to. That branches out to underfunding and understaffing, which is an indictment of mental health services for young people.

Young people make up 25% of the population. That is the group that CAMHS provides a service to, yet that cohort of young people only get only 10% of the entire mental health budget. That is also an indictment. Some 90% of the budget is invested in adult services. We have spoken many times in this House regarding spending on mental health budgets. Sláintecare recommends 10% of the overall health budget. Currently, in this country, the figure is probably less than 7%. The WHO recommends 12% so we are well below European standards for overall spends on our mental health services. CAMHS would get five times more funding if expenditure on it was made equivalent to that for adult mental health. That is a fact.

The report is so serious in respect of children's well-being that it warrants an independent inquiry. That inquiry should examine the funding and the staffing of CAMHS in both primary and secondary care. The report finds that staffing levels were to a point almost dangerous. Once there is lack of staff, mistakes will happen right across the board. Also important is the fact that when people are put under serious pressure there is burnout, lack of retention and demoralisation, and that seeps through an organisation. I acknowledge the amazing work those professionals who work in CAMHS provide. They provide an enormously important service. When children get the proper intervention at the proper time, the outcomes are hugely significant for those people. There is hope, positivity and a chance to recover. However, when there are situations such as those referred to in the report, situations which continue, the outcomes will not be very good.

I wish to make a number of points as to what such an inquiry could look like. The prescribing rates and the pressure on parents to accept medication for their children are very important matters. The overprescribing of certain drugs is highly unethical. I am sorry, but no child should be on antipsychotic drugs for years.

That leads to my next point, which is about the failure to provide alternative treatment. It is easy to give a child a medical intervention. There are circumstances where a child needs medical intervention via drugs, but not all the time, and that is very important in the context of the overprescribing of certain medications.

The underfunding of CAMHS, to which I have alluded, is very important. That goes to the heart of the matter, as does the lack of inpatient CAMHS beds in primary care.

Overall, the interim report is most serious in respect of children's health and well-being. If anything can come of the interim report and the issues to which it alludes, it is that they have to be addressed immediately. Otherwise, children - they could be our children or our nephews or nieces - will not get the treatment and intervention they need. Once that does not happen, we will fail all the children in respect of mental health services.

6:14 pm

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I am glad to have an opportunity to speak on this important matter. From dealing with issues relating to health on the health committee for a long period dating back to the health boards, I am deeply conscious of the urgent necessity to respond quickly. I acknowledge the work the Minister of State, Deputy Butler, has done already and the serious burden placed on her in the course of recent years.

The fact is that it was ever thus with the health service. The same issues occur again and again because this is a demand-led service. People do not become ill at a particular time of the day or night or a particular time of the year. They become ill at all times. It is absolutely necessary that the health service is capable of dealing with those situations when and if they arise. We here have all had to deal with the situations that have arisen in our respective constituencies over the years.

I will take a moment to speak about young people. I tabled a parliamentary question a number of years ago on the number of young people who self-harmed and were referred to hospital as a result. I was amazed by the age groups affected, down to as young as ten and nine years of age, an appalling situation. One can only imagine the concern of the parents in dealing with that kind of situation. In many cases there was more than one attempt at self-harm such that it was an ongoing issue. It did not go away. It did not go away with a change in the time of the year or the day or whatever else, nor did the degree to which they were affected. The issue arose again and again.

It is in that regard that we need to respond to the requirements as they arise. Every patient is a part of the experience. Every patient, whether a child, an adolescent or an older person, is a challenge to the system. They need urgent attention, and urgent attention needs to be built around their cases because it is not just one case but several cases, and the one moment of attention given to the one particular patient will resound many times. However, the question about the health service is and always has been how long we wait before we attend to the needs of the particular patient. For instance, I remember not so many years ago a patient being turned out of hospital in the middle of the night, at 4 a.m., with no place for the patient, who slept in a railway station, probably on one of the coldest nights of the year. It is appalling to have to admit to that in this day and age, when we are supposed to be responsive and supposed to have made huge strides - and we have - in respect of medicine in general, whether medicine for physical or mental ill health.

It is obvious that we have to provide for what the need is at a far quicker rate than we have done in the past. In general - and I know that the Minister of State is committed to this - we have to try to do what can be done to address those situations that keep occurring again and again. I know she does that all the time, but the system has to respond. The health service has to respond. The health service has to respond on the basis of the cases presented: how many of them there are, how often the patients have presented, what the nub of the problem is and how quickly we can respond. It should be remembered that there is no sense in responding five years later. That is cold comfort to the people now affected. Five years later a response is of no benefit. It is of benefit eventually, but five years is a long time. If you are waiting on the roadside with a puncture in your car tyre, five years later is no time to respond. I am not for a minute blaming the Minister of State for what is happening; this is endemic in the way the services are delivered.

We also need the patient, whether a child, adolescent or older person, to be able to access a residential place. Very often it is the only thing that can deal with the situation because under supervision something can and should be done and the medical expertise is readily available. The patient knows in the back of his or her mind that he or she is in the right place and is being looked after. The patient's family know in the back of their minds that the patient is in the right place and can be looked after. Consider the situation of there being no place for the patient - very often a very young patient - to go, which has often happened. The parents try always to get hospital accommodation of one kind or another. Even those patients have had to wait a day or a day and a half on a trolley. That does not change the situation. The patient is still in the same condition he or she was in before, and accommodation has to be made on an emergency basis to be able to deal with those kinds of situations when they arise, especially where supervision is required and, in some cases, where suicide watch applies. We cannot cover it up; we have to face it, deal with it, get that residential accommodation as quickly as possible and try to ensure we can deal with the patient and reassure his or her immediate family.

Like every Deputy, I have dealt with cases in the middle of the night where I had to comfort people who were desperate, including families of people who were seeking assistance and crying for help. In some cases, the patient’s family were at their wits’ end and could not understand why, given the advanced society we lived in, it was not possible to resolve their immediate problems. They knew that if the problem was not resolved, there would be consequences.

I do not want to go on for too long and I thank the Acting Chair for facilitating me, but this is an emergency. It was an emergency 20 years ago, and it has not changed since. The population has grown rapidly in the meantime and it will grow even more. There is no sense in saying that, because the population has increased, people have to wait longer. That will not solve the problem. We have to do whatever we must. We have to identify quickly the knots in the system that are delaying delivery and then deliver services as best we can in the shortest time possible.

6:24 pm

Photo of Ruairi Ó MurchúRuairi Ó Murchú (Louth, Sinn Fein)
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As people can see from all around me, I am operating the same paper-based system as the HSE. That is a joke, but the system is a joke that we need to fix. It is an easy fix that we have managed not to implement for many years.

Like other Deputies, I wish to thank the Mental Health Commission. I also thank Dr. Susan Finnerty for her excellent work on this. We will all say that we are shocked but not surprised. We in the House go around and around the garden when dealing with healthcare, particularly mental healthcare. We talk about how resources are not in place and how we cannot provide children with the services they need and to which they have a right. There are 617 children waiting for CAMHS in CHO 8, which is my CHO area.

I accept the comments about the large number of people involved in mental healthcare who are doing excellent work. A large number of people are also thankful to be able to access that service. However, many of the conversations in the House revolve around those who cannot access services. This report goes beyond even that, and we are now talking about lost children. That is unacceptable. I do not know of any time or place where it would be acceptable. We only know of 140 in one team, but the Minister spoke about 4,000 cases that needed to be reviewed. We need a timeline for that. The sooner they are reviewed, the better, but it must also be done comprehensively. I have been over and back with the Minister of State, Deputy Butler, on many issues. In fairness to her, we have tried to deal with them on an individual basis, but neither of us is a doctor and that is not the way to do business. Deputy Munster spoke about the case of a father, Richard, and his 16-year-old daughter, Amy, who were going through a crisis. We have all raised cases on the floor from time to time and Richard had already gone public on "The Michael Reade Show" on LMFM. We can sometimes get traction by raising cases and bring them to a head, but that is not the way to do business.

Numerous calls have been made, be it in respect of mental health reform or the work being done by my colleague, Deputy Ward. We know what the requests are. I do not know how many times the Dáil has to discuss workforce planning, but let us be clear, in that we cannot be sure that all positions will be filled next year, the following year or even the year after that. We speak about the lack of psychologists, occupational therapists and necessary services. If we move beyond mental healthcare to disability services and so on, those numbers are even greater. We must become far better and ensure that we have a throughput of people who can do this work.

Be it primary care, disability services or mental health services, people are sometimes unable to access CAMHS for their children because the services operate in silos. Ping pong is played from time to time. For example, a service might accept that a child with autism might have some anxiety, but it will say that it cannot provide help and the child must go elsewhere. A large number of families are being failed abjectly.

We can keep having these conversations, but we need to offer people solutions. Otherwise, more Deputies will raise individuals’ stories in the Chamber. Those individuals might be lucky and get dealt with, but doing that does not provide the solution that is needed across the board. The cases need to be reviewed as soon as possible. We need to put a better governance structure in place as regards anti-psychotic drugs. I do not know where someone can go in that regard. First and foremost, though, we need a timeline that we can present to our citizens for when the Government will provide a service that will deliver. Regardless of what area of healthcare we discuss – it is CAMHS today – we are talking how people are being failed abjectly.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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Next are Deputies Canney, Verona Murphy and Lowry of the Regional Group. They are sharing time.

Photo of Seán CanneySeán Canney (Galway East, Independent)
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I welcome the opportunity to contribute on this important issue and I thank the Government for acceding to the Regional Group’s request for this debate.

The report sets out a large number of issues and is a damning indictment of the services, which are putting children’s safety at risk. It is clear that poor clinical governance is a national issue across the health system. This is an interim report rather than the full report, but it highlights failures in the management of risk, the recruitment of key staff and the provision of standardised care across the mental health system. It is important that we adhere to the report and put in place the actions required. I heard the Minister on radio this morning. He spoke about consultation, speaking to someone and so on. To be honest, the time for talking is over. We need action, and the first action must be the recruitment of an assistant director of youth mental health services, as promised by the HSE. This post is needed and filling it should not take another nine months. It should be filled swiftly. Of course, rather than an assistant director, there needs to be a full national director of mental health services who reports to the CEO of the HSE so that there is someone who is accountable to the CEO and the Minister for what is happening and who ensures that everything is carried out as expected.

The report highlights the urgent need to reform the Mental Health Act 2001 to ensure that children’s rights are adequately protected when they need mental health services.

It is damning that €11.4 million of the €24 million allocated in budget 2022 went unspent. This funding was provided to make additional investments in the service. According to a survey carried out by nursing staff, there was a shortage of 700 mental health nurses as of November. This is cause for concern. According to the survey conducted across all CHOs, 4,000 children were on waiting lists as of October.

That is an alarming fact. The HSE has still not published either its prescribing audit or the compliance with the CAMHS operational guidelines 2019 audit, which it had promised to publish in quarter 4 of last year. This is another indication, I believe, that a lot of lip service is being paid to the problems that are there.

We cannot dilute this report. We cannot make allowances for the report. This report is telling us to get up and get going with what needs to be done. We do not need any more reports. We do not need any more working groups. We do not want any more bringing together of people to discuss what has to be done. The report is the template and what we need to do is have the courage to make sure that it is implemented.

From my reading of the report, I believe that we as politicians over the years have allowed this service to fail. This is to blame not Government, but politicians.

At the outset, both the Minister, Deputy Stephen Donnelly, and the Minister of State, Deputy Butler, praised the staff. While I concur wholeheartedly, we also must do something else; we have to apologise to the staff for not giving them the back-up they need to carry out their duties. I will publicly say that this evening. As a politician, I apologise to the staff who are trying to do a job without the services and without the back-up, note-taking and so on.

One will ask, what are we to do? We have a report; let us get the action done.

6:34 pm

Photo of Verona MurphyVerona Murphy (Wexford, Independent)
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There has been a lot of talk this evening. In the two and a half years since I was elected, I have stood on the floor of this House probably some 12 or 14 times to speak on CAMHS-related issues. I will say that the Minister of State, Deputy Butler, has always listened. I have always got action.

We are at the stage we are at tonight because Deputy Butler insisted on the review. It is a timely review. It was instructed in April. We have an interim report. It is a serious, damning interim report.

I commend the good staff that are in CAMHS. We have three CAMHS units in Wexford. There is not a full complement of staff, which in itself, causes problems. There are many issues for the staff within the CAMHS units. I do not want to label them but there are issues that certainly need to be addressed. I have voiced them on the floor of the House but I expect that this is where we now start. The days of talking, as my colleagues have said, do not come to an end but there has to be talk of action. I will not repeat what everyone has said.

I commend Dr. Finnerty on having the courage to bring out an interim report. I commend Dr. Niall Muldoon, who is the Ombudsman for Children. I commend Mr. John Farrelly. These are all people from whom we have heard the problems previously but we now have an in-depth review that the Minister of State instructed. Let the Minister of State not forget that. It is a proactive step and it has to continue in that frame.

Money, in many of our health services, is not an issue. It is an issue here. There are some disparities that need to be addressed. We need to provide a dedicated fund to CAMHS. A dedicated CAMHS fund is strictly what the report says. For instance, in Wexford, we had an issue with a child psychologist. We had a child psychologist available to us for two years. She was ready and able to take the position but, because she was not part of the panel, she was not eligible. That type of crap - excuse me putting is straight - has to change. We cannot have a system that obstructs the focus of helping our children with their mental health. We have to be practical. We are short-staffed. We have a retention and recruitment crisis. We cannot keep saying we have it; we have to do something about it. If a child psychiatrist who held the position previously was available, it is only a matter of somebody knocking heads together and saying that here we have a child psychiatrist who wants the job and to give it to her. We now have a child psychiatrist but that is not the point. Two years went by in which we did not have one.

I look forward to the future. I look forward to assisting the parents who will come to me with their problems.

Photo of Michael LowryMichael Lowry (Tipperary, Independent)
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Like all the damning reports on the failings in our health service, this interim report on child and adolescent mental health services struck an alarming cord. In the mid-west, we have 116 children on a waiting list for assessment for over a year. Many of these children are from north Tipperary. This failure affects our children and young people, our vulnerable and voiceless citizens. It is a disgrace, an abomination and a scandal. It is heartbreaking to learn that so many young people have been utterly failed.

People are angry. They are disgusted and above all else, they are frightened. The mental health of our children and adolescents has been compromised.

The question on everyone's lips is, how is it possible that so many cases within CAMHS system were simply lost? How is it possible that cases were not followed through once a child reached the age of 18? How were young people left taking anti-psychotic medication indefinitely without the required monitoring that is essential to their well-being? These are not isolated incidents. The fact that it happened in four out of the five CHOs makes this a national scandal of the highest order.

This lack of follow-up has left some families without a review appointment or advice about their child's care while on medication. These practices have grave repercussions for a child's physical and mental health. It cannot and should not be tolerated.

It is evident from the report that there are serious deficiencies in leadership, management and integration structures that must be urgently addressed. There is a massive problem with staffing deficits. The CAHMS interim report points to stress and burnout in a significant number of team members.

There is insufficient staff to provide a safe level of care across the vast majority of healthcare services. Thousands of staff have fled the Irish healthcare service. Excessive demands are being placed on remaining and existing healthcare staff. They are overwhelmed and simply cannot cope.

A vital health service cannot run successfully unless there is sufficient manpower in place to keep the wheels turning. Until we succeed in retaining and recruiting staff, we will not see improvements in our health services. Providing extra capacity and additional services is absolutely necessary but it is a wasted exercise if there are not sufficient people to allow them function.

Since this damning interim report was made public, the Minister has said that the HSE is seeking to appoint a national clinical lead for youth mental health, which will bring consistency to how teams across the State are regulated. I welcome it, and I also welcome the recruitment of an assistant national director to ensure the kind of integration that the interim report has highlighted. This will bring the provision of mental health services in line with the way in which adult mental health services are delivered.

While such announcements are welcome, it is critical that they materialise as quickly as possible. Every action taken to address the dysfunction and anomalies is welcome. However, we must also acknowledge that we are attempting to close the door after so much damage has been done to defenceless victims. It is certainly cold comfort to the children, adolescents and their families who have fallen victim to the recent malfunction of the service.

The Minister and Minsters of State, together with all Members of this House, have an obligation and a duty to ensure effective action is implemented with urgency.

Photo of Niamh SmythNiamh Smyth (Cavan-Monaghan, Fianna Fail)
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I wish to begin by acknowledging this catastrophic report, which has been released. I commend the Minister of State, Deputy Butler, on insisting that this happened, that the research was done and that we got a real drill-down to the detail of where the system is at. We have all known for years that there are difficulties and problems but there are some really stark and frightening outcomes in that report.

As the Minister of State will be aware, I have on many occasions raised with her the issue of mental health, both with adolescents and children and with adults.

I hate to admit it, but I firmly believe that in CHO1 and especially in Cavan-Monaghan, we have one of the highest rates of suicide. I take this opportunity to plead with the Minister yet again to deliver Jigsaw in Cavan-Monaghan. He has made huge inroads in delivering a service in CAMHS in Cavan-Monaghan, but the reason I ask for Jigsaw specifically is that visibility and recognition are hugely important. We talk about teleservices or tele-therapies for young people. I still strongly believe in face-to-face contact. We know services are available at the end of the phone. However, we also know that when people are at their darkest moment, it is simply too late.

I have never seen anything like this Christmas and New Year in Cavan-Monaghan. There was a huge loss of life, especially of young people, because of suicide. As the Minister will be aware, I have campaigned for a long time for Suicide Crisis Awareness, SCA, nurses and I am grateful to him for the delivery of SCA nurses. I strongly believe in them. They are very effective. We have seen that they have worked and they are a huge component part of mental health services. I wish the two nurses who took up those roles in CHO1 the very best in their important and significant roles. They can have a profound impact on the lives of people who find themselves in a dark place.

Everyone around the House has been able to share experiences from their constituency offices. I take this opportunity - it is great to have it - to speak frankly and openly with the Minister. One experience I can share with the Minister is of a 15 year old girl who was desperately crying out for help. She had the presence of mind to tell her parents, her social workers and the staff in her school that she needed help, but she had to fight the system to get it. When I say fight, I mean that her parents should not need to ring a Deputy to ask for help and to explain that their child needs intervention, specialised care and a bed. When I rang her school, with the agreement of her parents and the community around her, to find out how much on the radar of the school she was, I was told that in a school of 500 children she was in the top five of the children at risk. The school was able to recognise that and yet to get the professional help she wanted and knew she needed, she had to fight for it. That should not be the case. She should not need to come to me. I was more than happy to help her and when I made the necessary calls, she got help, but she was at the end - when her family rang me they said they had never phoned a Deputy before. They were sure it would not be something I could help with. Thankfully, I was able to help, but she should not need me to help. In Cavan-Monaghan we do not have the residential care and services required for children and adolescents. When children and adolescents find themselves in that position, they end up in clinical care alongside adults and that is simply not right. That girl got a bed in Linn Dara. I am grateful for that bed and the staff there were able to provide the care she needed. I am so glad to tell the Minister that because of the specialist care, that young girl is around today to tell that story. However, she and her parents would be the first to admit that had she not received that care and intervention, that might not be the case. That is one example. We all have endless numbers of examples of types of crisis and cases we have heard about. I join with all the voices, including that of the Minister, to concur that what is needed is oversight and accountability.

We have heard many times tonight that recruitment is an issue. We know that it is an issue in the HSE. Does CORU not have a part to play in this? I am aware of professionals who wanted to work with the HSE and have had to wait nine to 12 months to make the cut, to get through the paperwork and the nonsense that goes on with bureaucracy in order to get on the panel, to be part of the system and to take up the positions they are more than qualified for. CORU must be part of the solution.

I will finish with the case of Dan Hogan. He is not a young person I knew. I know his brother Rory Hogan. His mother spoke openly and honestly on Drivetime this week. I was driving to the constituency when I heard her interview with Cormac Ó hEadhra. Elaine Clear gave the most harrowing account of what happened to her son. He went into mental health services at the age of 13 and he died at 17. This happened eight years ago. What upsets her most when she hears what we are talking about, hears these debates and reads that report, she is crippled by the thought that nothing has changed. You would have to stop the car, stop in your tracks when you hear about the experience she had from when he was 13 until he lost his life at 17, what they went through to try to get him the help and services he needed. This was her experience. When they got him into clinical care, he was brought to the clinician who was looking after him who gave his father the option of either signing the boy into a service she described as a prison, where the doors were locked - he went through five locked doors to get to the room he was going to be cared for in - or the service would get a court order to sign him in. His mother did not want him to have a record in his adult life so she agreed to sign him in. There were no phones. No parent was allowed to stay with him. It is bizarre that would be the case. When would a parent ever be asked to leave a child? They were asked to leave a child who was in that kind of deep, dark, hollow, black place that we cannot imagine, told they could not stay with their child, could not sit with him. She would have given anything to stay the night with him. She, her husband and her brother would have rotated. They wanted to be with him. They were not allowed. They were locked out of his care. She told me that her son eventually got a phone somehow. He was not allowed phone contact or anything like that but he got a phone and he was whispering on the phone as though he was in prison. He was asking his Mam to take him out, to collect him, to get him out of there. She has to live with that now.

It must of course be acknowledged there are great people there who are under huge pressure. Mental health services and especially CAMHS is in very good hands. I know that the Minister of State leads this with her heart as much as her head. I would like to support her in any way I can to do the work she is doing.

6:44 pm

Photo of Paul DonnellyPaul Donnelly (Dublin West, Sinn Fein)
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I welcome the chance to speak on this issue. I thank the Mental Health Commission and all those who work in the extremely difficult area of mental health and especially in youth mental health, including in my area, the Dublin 15 suicide awareness group Genesis Psychotherapy and Family Therapy Service CLG, Jigsaw and all the private counsellors and therapists who provide support to young people and who hold those young people at risk who should be in services such as CAMHS. To be honest, the publication of this damning interim report on CAMHS has not shocked anyone who has any knowledge of the system young people have been trying to access for many years. Those of us who have worked with young people will have experience of the significant challenges faced in trying to access mental health support services for children and young people in CAMHS. The report describes a situation of children who should have had follow up appointments including to review prescriptions and to monitor medication, waiting for an appointment for up to two years in some cases. It is absolutely appalling.

In CHO 9, which covers my area of Dublin West, 153 people are waiting up to six months, 74 young people are waiting six months to a year and ten children are waiting over 52 weeks, and that is the lower end of the scale. If one looks at the reports from all of the CHOs, CHO 9 is operating the best - if you could describe it as that - yet those numbers should shock anyone and appal everyone.

Across the State, there are more than 4,043 children on CAMHS waiting lists. Statistics from Mental Health Reform state that 741 children with mental health difficulties attended emergency departments from January to November 2022. They were in such dire need due to their mental health state that they attended the emergency department of a hospital. People who attend an emergency department because of their mental health know that the services do not exist there and that they will be left sitting for up to 24 hours to be told there will be an appointment for them within four to six weeks. They are in such a state of distress that they attend hospital and they are told "Sorry. There are no services here. You will have to go off and, in a couple of weeks' time, we will have an appointment for you."

The HSE audit of CAMHS, including both the prescribing audit and the compliance with CAMHS operational guidelines audit, were promised to be completed in the fourth quarter of 2022. They still have not been published, as per the HSE's statement on 23 January. Despite the lack of availability of public CAMHS beds, the HSE does not have any memorandum of understanding agreements in place with private providers for the provision of private mental health beds for children and adolescents attending CAMHS. It is failure after failure in pretty much every area. This is no surprise to anybody.

Approximately half of the budget, some €11.4 million of the €24 million, allocated to mental health services in budget 2022 for the development of new services was not spent. A survey by the Psychiatric Nurses Association revealed the existence of over 700 mental health nursing vacancies in mental health services throughout the country. I know from speaking to and working with people who work in the HSE, in mental health services and in Tusla that some places are too stressful and much too difficult for them to work in and they burn out very quickly. The support services are not in place for the workers and that must be addressed. Otherwise, we are not going to hit any of the targets being set.

It is clear that CAMHS is not working and that we must put in place an urgent strategy to tackle the crisis. It is time to hold the Government to account as well. Every child and young person who cannot access a service in an appropriate timeline means the Government has failed them. I refer to those who are responsible for providing mental health services for children and young people in distress. If they cannot access that service in a timely fashion, we have failed them and the Government has failed them and this country has failed them, so we must get this right. It is way too important. Children's lives and young people's lives are at risk as we stand here and speak.

6:54 pm

Photo of Mattie McGrathMattie McGrath (Tipperary, Independent)
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The interim report on child and adolescent mental health services published earlier this week, while deeply alarming, was unfortunately not in any way surprising. Families up and down the country with children and young adults experiencing mental health difficulties are all aware of the huge failings within CAMHS.

The CAMHS report shows that a radical overhaul of mental health services for young people is urgently required. I fully agree with the views of Mental Health Reform that the crisis in CAMHS requires an urgent national co-ordinated response. The Government must absolutely prioritise urgent recruitment within the service, particularly in the area of CAMHS intellectual disability specialists. My office has, unfortunately, been inundated in recent months with families of children and young adults who have been left in limbo, pushed from pillar to post and, quite simply, desperately failed by a system that is supposed to assist them when their children and young adults reach their lowest points in their life. It is just so sad.

My experience of the greatest failings is that when these vulnerable children have a dual diagnosis - our must vulnerable children - they are being failed even more dramatically as no one wants to take responsibility. Disability services say they do not have the expertise. I salute the staff who are in these services. The vast majority of them, who are doing their very best, do not have the capacity to support children who are displaying mental health difficulties. CAMHS has pushed these children back to disability services claiming that their autism is the reason for their difficulties and that they, therefore, do not have the capacity or expertise to support them. It is particularly clear that these children, and their families, are being failed and they are the responsibility of the Government. Recruitment difficulties is not a sufficient excuse to leave children in desperate situations with no support or assistance.

The lack of CAMHS intellectual disability, ID, specialists is a serious failing and must be urgently addressed. I welcome the recent appointment of a new CAMHS ID specialist in CHO 5 who serves south Tipperary. However, she needs a full team around her and the absence of appropriate CAMHS ID units in this country is simply appalling. The experience of families that have come to me in tears and in fear for the lives of their children is an abusive situation. The State is literally abusing these families and putting them in the most awful of situations. I do not say that lightly.

I dealt with a case involving a teenager who is self-harming, has been out of school for long periods due to extreme levels of anxiety and is expressing suicidal thoughts. It seems that because of a diagnosis of autism, CAMHS can offer no supports. The services say that the issue is the autism diagnosis and that it is a matter for disability services. Disability services say they cannot support this child through these mental health difficulties. The child is left in limbo and the only option is for the child to present to the paediatric ward or the accident and emergency department of Tipperary University Hospital, TUH, which can give no support. A CAMHS specialist may or may not attend. Having spent two weeks in hospital, this child was sent home with "a safety plan" for the parents that basically consisted of "if you or your child's life is in danger, call emergency services". That is just awful. That was the extent of the services available for this child. The mother reported sleeping on the floor outside of the girl's bedroom every night as she feared for her life and his life.

I have been dealing with another case, involving a teenager of 15 years of age who is experiencing severe mental health difficulties. I am sure the Minister of State comes across such cases every day of the week. The CAMHS psychiatrist refused to see this child. Again, the service said that autism is the reason for the child's difficulties. Despite being admitted to St. Patrick's University Hospital in Dublin for a period of ten weeks, the CAMHS psychiatrist discharged the child and refused to see him stating that the child had no treatable mental health diagnosis. The time given to assess this child by the CAMHS psychiatrist was a mere ten minutes - deich nóiméad. It took ten minutes to say that he had no treatable mental health difficulties despite having spent ten weeks in a mental health unit for adolescents. Again, this child presented to TUH in a very severe state. He waited four days for a psychiatrist to come to carry out an assessment. The CAMHS psychiatrist came and, again, said it was a matter for disability services due to the child's autism diagnosis. Thankfully, after much representation and phone calls, another psychiatrist came to assess the child and he has finally been taken under the care of CAMHS and is being seen by a psychiatrist. However, the fight continues with disability services for them to provide supports to deal with the other side of the child's diagnosis, as he has a dual diagnosis.

Another case is that of a young 14-year-old child who had no access to a psychiatric assessment following the retirement of the CAMHS ID psychiatrist in CHO 5.

Thankfully, after much lobbying by the child's parents, the HSE approved funding for the child to be assessed by a psychiatrist who travelled from the UK. This psychiatrist described this child's case as one of the most challenging and difficult to manage presentations he had encountered in over 30 years as a consultant practising in a city of 3 million people.

While the mother of this child had regular interaction with the psychiatrist, she was left to administer huge doses of medication with little to no clinical oversight or monitoring of the child's vitals. This child requires an urgent residential placement yet they wait and plead for the most basic of services and limited respite. This family is left in circumstances that no family could or should have to endure. They have been in crisis for almost two years but they have gone beyond crisis. The mother is facing extreme burnout and they have to fight and fight for limited supports. They need urgent intervention and supports from this State and they are being failed. The parents will not rest until the child receives an urgent residential placement. It is so badly needed. Procurement is spoken about. They cannot get houses and staff. It is an awful situation. We have had several meetings with this family and the HSE.

Another case I dealt with involved a primary school-aged child attending CAMHS. He was prescribed high levels of medication that made him physically sick. When he ultimately refused to take the medication because of how ill it made him, he was immediately discharged from CAMHS. It could offer him no further assistance other than medication.

I could go on and list many other cases with which I am dealing and I thank my staff for dealing with these traumatic cases but, unfortunately, it is the same story. CAMHS could offer no supports. "Present to the emergency department" is the answer people are faced with. We all know a emergency department is not a nice place even if you are in full health and only have a cut finger or a broken bone. I do not need to tell anyone here that advising a child with autism experiencing severe mental health difficulties to attend his or her local emergency department is not in any way appropriate. It is hugely inappropriate for both the child, his or her family, the staff and management in that hospital and other patients. The setting is not appropriate and will often only lead to further distress for the child and could lead to distress for other children attending paediatrics but this is the best that our current mental health services can offer.

The families with which I have been dealing, and they are many, do not want to bring their children to the emergency department and cause them and others further distress. Their love and care for their children are being abused daily by the HSE. The HSE get away with wilful neglect of our most vulnerable because they know these families will not abandon their children despite how utterly burnt out they are. I wish we could see light at the end of the tunnel but we cannot. We must fight on for these people and have a national response to sort this out. These are just a few cases. They are told to present to Tipperary University Hospital or other emergency departments and they get no services.

Our most vulnerable children are being failed and we cannot stand back and say "sorry we don't have the staff or the expertise". We cannot watch them being pushed from pillar to post. This requires a full overhaul and I am pleading with this Government to take this matter seriously because the distress being caused to families, their children and their communities is awful. I am begging the Government to do something because as somebody said earlier, it is 20 years too late. It just has to happen.

7:04 pm

Photo of Joan CollinsJoan Collins (Dublin South Central, Independents 4 Change)
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I thank Dr. Susan Finnerty for producing the interim report. It should be noted that in every Mental Health Commission annual report, she always has a section on CAMHS and always makes the point that the situation is dire. This interim report has shown once again a total breakdown in our health services. We see again some of the most vulnerable people in our State being let down again and again by the services that are supposed to look after and care for them and be their safety net when they are ill. We see children lost in the system; children left on medication for years without any sort of review; children waiting for days in emergency departments; some reaching 18 without transfer to adult services; chaotic paper-based record keeping; and staff not properly trained, not properly supervised, overworked and overwhelmed. Everybody knows that this is not an attack on those workers. They are putting their full time into their work with children who need support. All this is from a sample of just 10% of the 6,000 children in CAMHS. We know from the Maskey report that there were 240 children with serious shortcomings in their care in south Kerry alone. These are the children who were lucky enough to get into CAMHS in the first place. The report found acceptance rates of referrals range between 38% to 81% in different CHOs without any clear reason why. How many more children have been lost and let down by this system? How many cannot even get into it?

Mental Health Reform, MHR, has said that 4,043 children were on the CAMHS waiting list as of October 2022 and 741 children with mental health difficulties attended emergency departments last year. As of last October, only 37.1% of the Maskey report's recommendations had been completed. The HSE audits of CAMHS promised by the end of last year have not yet been published. No agreements are in place with private providers for children and adolescents attending CAMHS despite the lack of public beds Around half of the €24 million allocated for new mental health services in the 2022 budget has not even been spent. There were over 700 mental health nurse staff vacancies in mental health services as of last November.

We knew already from the Maskey report and the Mental Health Commission's 2021 annual report that this system has been failing. The Government has known this system was failing yet clearly not enough has not been done to help these children and their families.

MHR has said the Government's approach is not working. Professor Matthew Sadlier from the IMO says the Government has implemented unfunded and under-resourced structural changes with no consultation with those on the ground. Funding for CAMHS is not ring-fenced and must compete with other services. We know we are facing a shortage of hundreds of child psychiatrists by 2030. People working in these services are warning that this situation will just get worse. I hope that from today, the situation will get better for those workers.

The report found that only one CHO provided excellent services. This was the only CHO with electronic records and it was not run by the HSE. This was actually put to the Government at the United Nations Committee on the Rights of the Child on Tuesday. How can this country be the location for the offices of all the big global tech companies and still run paper-based records for the care of some of its most vulnerable children?

This system is clearly not working. It is clearly letting down thousands of children in this country. The Mental Health (Amendment) Bill 2023 needs to be brought forward immediately. I heard the Minister of State say this will happen. She will not find this side of House wanting when it comes to pushing the legislation through very quickly if necessary. We must legislate full rights for everyone receiving mental health services in this country and set out clear responsibility when those services fail them.

The next budget needs to properly increase our mental health spending as a percentage of total health spending. The World Health Organization recommends 12%, the UK has 13% and we have 5.5%. This needs to be in the form of spending increases. It needs to be put towards developing new services and needs to be properly planned, allocated and ring fenced for different services. The post of national director for mental health in the HSE needs to be immediately reinstated. Having an assistant national director is not good enough. The national director needs to report directly to the CEO of the HSE and needs actual funding to develop new services and a new administrative system to take pressure off the existing system.

This crisis is not acceptable, it never was acceptable and it should never have got this far. We need immediate action to protect these children and we need a system with proper planning, oversight, transparency and funding to make sure these failings never happen again.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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It has been a pretty grim week for our health system, particularly our mental health services, both for those who work in them and those who rely on them. One of the grimmest aspects of it is that we are here at 7.50 p.m. on a Thursday discussing this important issue. Obviously the political agenda of the week was dominated by relatively minor electoral infractions by both sides of the House.

On Sunday night, I learned that this report was going to be in the media the following morning. I pay tribute to the main author of the report, Dr. Susan Finnerty, and the Mental Health Commission for driving that report. It is fair to say they have done the State some service. In the report, we learned of poor monitoring of medication, children waiting for days in emergency departments for psychiatric care, and children left unreviewed on antipsychotic medication for years. Deputies have said that this is completely contrary to best practice. It should not take ordinary people to know that. We are supposed to have a health service staffed by experts. The report states that staff are exhausted, overwhelmed and inadequately supervised. It states that psychiatrists are not trained to work with children, that there is poor risk management, poor clinical governance, and chaotic paper-based record-keeping. The area that I represent, Clare, is not identified in the report but it was identified inThe Irish Times. It is obviously part of the mid-west community health organisation, CHO, which covers Clare, Limerick and north Tipperary, where it was found out that there were 140 open cases. A serious risk to the safety and well-being of children accessing CAMHS was identified, including the 140 with open cases who had been lost to follow-up.

The immediate response from the HSE was, as it typically is, a defensive one. A senior psychiatrist from the HSE was on RTÉ the next morning to say that the HSE had found that out before the Mental Health Commission report, as if it was somehow a defence that the HSE had seen it a year before the Mental Health Commission identified it and reported on it, but had seemingly done nothing about it. It is beyond me how that came to pass. The part of the report that I found perhaps most depressing was the discussion of systems. I have long held the view that we have no systems anywhere in our healthcare. We have excellent people but no systems. It seems that, as a nation, we do not do planning particularly well and we certainly do not put systems in place. It might be something to do with a post-colonial legacy. I do not know but we do not do it.

The report states:

- One CHO in our review had a system that they had devised themselves which allowed generation of reports but did not provide electronic records.

- Only one CHO had electronic records; this system was provided through an independent agency which also provided the CAMHS service.

It is important to highlight that it was an independent agency. I do not highlight it with a view to suggesting that independent agencies should be providing all of the services within CAMHS, but if they can do it, surely to God the HSE can put a system in place. The report continues, "A small number of teams had independently tried to set up basic information systems within their own teams, through their own knowledge of information technology, to increase efficiency and monitor patient files and outcomes. But time spent on such matters takes away from time on patient care and national system would be the most efficient and effective manner of dealing with this." It later states that paper-based files were the norm rather than the exception, that those paper-based files were often incomplete and contained handwritten notes which were illegible. I would welcome it if the Minister spoke on that. It meant that people could not travel out of an area to receive a service but had to be provided with the service in an area.

If that was not depressing enough, on Wednesday, we woke up to learn that Professor Martin Curley, who was tasked with delivering the digitisation of health services across the entire HSE, had resigned from his position, saying there were bad actors within the HSE blocking the implementation of this. He helpfully pointed out that Ireland had been loaned €200 million from the European Investment Bank. We have one of the biggest budget surpluses in Europe and we have been loaned money from the European Investment Bank. Even then, we cannot put information systems in place. Who is blocking this? I am sick of the HSE defending this. Over Christmas, the Department defended itself and said it was the HSE's fault, while the HSE said it was the Department's fault. Frankly, I do not much care. I know the Secretary General of the Department of Health was appointed to the board of the FAI during the week. If he can bring his defensive capabilities from our health system to the FAI, we may have a team with a defence like Italy, but Italians return to a functional health system. We in Ireland have an utterly dysfunctional health system. Deputy Joan Collins pointed out how little we spend on mental health. It is quite true that it is utterly inadequate. We spend as much money on health in this State as Austria and Denmark spend per capita, but we do not get a return. The complete lack of systems is part of that.

7:14 pm

Photo of Seán Ó FearghaílSeán Ó Fearghaíl (Ceann Comhairle; Kildare South, Ceann Comhairle)
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The Deputy is way over time and testing my gentle nature.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I think it is important that the Minister identifies who is blocking this and removes them and the blockage. Systems should be put in place so that 140 vulnerable constituents of mine will never again be lost in a system that they rely on for help, protection and a decent healthcare system. I think it is an abomination that we are discussing this at 8 p.m. on a Thursday evening.

Photo of Seán Ó FearghaílSeán Ó Fearghaíl (Ceann Comhairle; Kildare South, Ceann Comhairle)
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Well, Deputy-----

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I appreciate that the Ceann Comhairle does not set the agenda. It speaks volumes about the priority of our political system.

Photo of Seán Ó FearghaílSeán Ó Fearghaíl (Ceann Comhairle; Kildare South, Ceann Comhairle)
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Listening to Deputy McNamara and the previous contributors, I find myself regretting that custom and practice ordain that I or anyone who operates from this Chair cannot take full part in debates, but I will make this contribution. This has been an exceptionally important debate. Whether it happens on a Thursday evening or at any other time does not take from the importance of it. The contributions that have been made have all been valuable. The issues that are being touched on impact on us all and all of our families. The one commonality in all of this is our common commitment to ensuring that we build the best possible service that our children and adolescents deserve. I would utter one word of caution to everyone, which is that as public representatives, we need to be conscious that this is a particularly sensitive area. It behoves us to build some degree of hope and instil some confidence in people who need the services that they will not be abandoned or left without care and that all of us are committed to looking after them.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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Do we do that by ignoring a report that is completely damning?

Photo of Seán Ó FearghaílSeán Ó Fearghaíl (Ceann Comhairle; Kildare South, Ceann Comhairle)
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I do not want to ignore anything and I am sure the Minister and Minister of State will address that in their response.

Photo of Stephen DonnellyStephen Donnelly (Wicklow, Fianna Fail)
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I want to make a few comments, having listened intently to the debate. I have reviewed some of the core documents about implementation of Sharing the Vision and of CAMHS, as well as the report itself, during the debate. I want to make a few quick points. I thank colleagues. I have found this debate useful. It shows that Dáil Éireann can work well when we are united on a common goal, which we are on this matter. Our goal is to have the best possible services for people who need them, which they can get as quickly as possible. The full answer to that lies in these reports, which are the implementation plans for Sharing the Vision, and Sharing the Vision itself. As I said, part of the answer is CAMHS, but much of the answer lies outside CAMHS, including prevention, lower acuity care and early intervention.

There has been much talk about recruitment and retention. Some 10,500 people work in mental health services, with an extra 500 having been added in the time of this Government. There has been a flurry of additional recruitment activity recently, led by the Minister of State, Deputy Butler, who has really pressed the system to get moving on many hundreds of sanctioned posts that were not being actioned and recruited for to our satisfaction. The higher specialist training posts, for non-consultant hospital doctors to go on to become psychiatrists, have to be expanded.

They were expanded last year, when the number rose from 22 to 46. That was in one year so there has been a big increase and we will continue to go further. My view is we need to double college places for healthcare professionals. It is something that I am working on with the Minister for Further and Higher Education, Research, Innovation and Science and I have met several universities about this. We must have a strong pipeline of new healthcare professionals coming forward. The new consultant contract will help. It is a very attractive contract. It will help to hire the very best people. The NCHD task force is going well to make sure that NCHDs have what they need in their training. Deputy Ward raised the issue of panels earlier, and I agree with him. There is work to be done on the panels. They are not working as well as they need to in this and many other areas.

The second point I want to make is on waiting lists. Quite rightly, Deputies have been focusing on the 4,000 children who are waiting. Importantly, 1,500 are waiting less than 12 weeks. They are all of concern, but the greatest concern is for those who have been waiting more than 12 months, of whom there are 579, and those waiting between three and 12 months, of whom there are around 1,800. The Minister of State and I, along with the HSE, will focus intently to drive down the number of those waiting too long. We have had success in other areas. Over the past year and a half, the total number of people waiting for an outpatient appointment for more than 18 months has dropped by 50%. The numbers waiting more than 12 months have dropped by 40%. These are big falls, because we have been targeting the long waiters. We will do that here too.

The final matter to which I will refer is political will. One or two Deputies asked whether there is political will to deal with this issue. I will make a few points in this regard. The Government is absolutely committed to ensuring that we have the best possible healthcare services for children, adolescents and adults. That is why one of the we have a Minister of State with responsibility for mental health and older people. The Minister of State, Deputy Butler, has succeeded in increasing the mental health budget by €200 million in the lifetime of this Government. The overall budget has risen from €1 billion to €1.2 billion. Do we need to go further? Of course we do. However, a 20% increase in just three budgets is significant. This speaks to the Minister of State's and the Government's prioritisation of this matter.

It was the Minister of State who sought this report. The Mental Health Commission can report on whatever it wants. It agreed that it would compile this report, and that is its choice, but it was the case that the Minister of State actively sought it. The Minister of State wanted to ensure that a light was shone on these issues. She fought very hard and succeeded in securing a full national audit on medication in the aftermath of the Maskey report and other issues.

I work very closely with the Minister of State and I assure that House that she is pushing the HSE very hard. She is pushing it harder at times than the HSE would like. She is seeking these detailed reviews and big increases in funding and pushing for recruitment in order to ensure that we have the money, staff and strategy that are required and that, through our work in this area, we know where the challenges lie. In knowing where those challenges lie, we can all work together in this House to meet them.

7:24 pm

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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And a digital IT system.

Photo of Seán Ó FearghaílSeán Ó Fearghaíl (Ceann Comhairle; Kildare South, Ceann Comhairle)
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The Deputy can wait and we might hear the answer.

Photo of Mary ButlerMary Butler (Waterford, Fianna Fail)
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I want to thank everyone who has been here for over three hours. We have listened intently. That is one thing I always do whenever I sit on this side of the House. I listen and take notes.

It has been a really difficult week. There is no point in saying otherwise. Deputy Niamh Smyth summed it up when she said that you should not have to fight the system. We all see that you have to fight with the system even though we have really good people working within it. In that context, Deputies Ó Murchú and Munster referred to a particular case. That case was brought to my attention yesterday afternoon by Deputy Fitzpatrick. It relates to a young child in the midlands. There were an awful lot of difficulties involved. Thankfully, by yesterday evening, through my efforts and those of my staff, that child got an inpatient bed. It was the first I heard of it yesterday afternoon. There should not be a case where someone has to go to a politician to try to get access to a bed or the necessary supports that are needed.

There is something we must be cognisant of. Many comments were made today. I do not have a medical background of any sort, and nor do many people here. This is about dealing with the most complex, challenging and vulnerable people and consultant psychiatrists make a decision after many years of being trained and many years of experience. I will always accept and respect that decision because I do not have the medical wherewithal to challenge it. We hear a lot about young people who do not gain access to CAMHS. Only 2% of all young people with mental health difficulties need the support of CAMHS. That decision has to be taken by a multidisciplinary team. It determines whether the child meets the criteria or not. I am concerned that it varies widely from 38% to 81% depending on which CHO area a person lives in. That is something that I am looking closely at.

I have had many meetings this week with the Minister and the HSE. I had a meeting with the Taoiseach earlier today. We have to push so hard on the IT systems. It is not acceptable to still use paper files in 2023. That is really difficult. Another area in which I have zero tolerance relates to governance. There cannot be a situation where governance and standard operating procedures are not in place. The standard operating procedures were introduced in 2019. We dealt with Covid and a lot of other issues, but it is down to me now to push this as hard as I can. I will immediately seek to ensure that all CAMHS multidisciplinary teams have an acceptable level of staffing. We hired 90 people in December. Much of the hiring goes on towards the end of the year. There are an additional 85 people working in CAMHS in the last two and a half years since the Government came in. Yes, we need more. We have 280 staff under recruitment at the moment. Across the multidisciplinary teams, staffing sits at 64%. It varies higher or lower depending on location. That is an area where we are challenged.

There was much talk about children lost to follow-up. I do not agree with the choice of language used in this regard, and I will explain why. There was one team in CHO 3 which was identifiable. In that one team, 140 children who had open cases had been lost to follow-up. The children had not been lost; the case had been lost to follow-up. The team had already started the process of a desktop review of these cases and had informed the Mental Health Commission when it came in. A further 28 cases have been looked at. That is 168 cases in total. They are being actively followed up. Consultation has been held with most of the children in this case and their families.

I remind everyone that HSE live is available to support any children or families with concerns. The freefone number is 1800 700 700. We have 21,000 children who avail of the help of CAMHS. As of yesterday evening, just under 40 contacts had been made on that issue and eight had been escalated. I reassure people that the phone line is working and the supports are being put in place.

We have a lot more work to do on this. There will be another motion next Tuesday night and I will be in here to take it. I will also be in the Seanad next Wednesday. We will make every effort that we can to make sure that we will improve the system. I thought the Ceann Comhairle's words were very wise. Some 21,000 children receive support from CAMHS. They will have appointments again on Monday morning and their families will be listening. My job is to build confidence in the system because there is a lot of good work, really good work, going on. That was stated in the report.

CAMHS staff work extremely hard to try and provide a good service. That is stated in the report. We are aware that many young people and their families have received excellent care and treatment. It is stated on page 20 that: "We were pleased to note that, in the majority of the sample of files reviewed, the physical monitoring was completed for children and young people with ADHD on stimulant medication." My main concern in the context of children on stimulant medication was whether physical monitoring was taking place and whether such medication was being overprescribed. There was no evidence of that in the report. I thank all the Deputies for their time. I appreciate it.