Brendan Ryan (Labour)

I missed that at the launch and it is not quite clear in the Minister of State's own script. I am glad that is true because it is extremely important. I am here the day after I discovered a commitment not to impose a large debt on Cork Airport was not really a commitment but a hope. I accept the Minister's bona fides. Let me not get involved in silly nonsense. If the Minister says so, I accept that at this moment the intention is to fully fund it and I will move on.

I want to say something that may get me into trouble. It is important that early 21st century humanity gets it into its head that unhappiness is not an illness and that the remedy for every individual's sense of discontent with the world and his or her position in it is not a service provided by the State or, worse, some self-appointed guru. I am very taken with a recent definition of "guru". A "guru" is the name used for charlatans by journalists who cannot spell "charlatan". I am sceptical. This is not entirely my own view but is an issue about which many people in the area of caring for people with mental illness are concerned. For every new manifestation of human unhappiness the response is to provide some therapeutic service. All of us must live in a different world in which there are degrees of isolation and change due to family breakdown that did not exist before and, to a degree, we must be able to tell people that part of this is the process of maturing. Let us not expect the caring services to provide for everybody. The mental health services must focus on three areas — those who are demonstrably psychotically ill, those who are abnormally emotionally distressed, and those who, without support, are likely to fall into one of those two categories in the future.

I welcome the intent of the report. It is a fine idea that the users of services should be listened to. It is probably frustrating to have to read this over and over again. It the malaise of large organisations, not just public ones that many stakeholders perceive that others do not listen to them. For simplicity let us refer to stakeholders in mental health as those who provide and use services and see that as a large organisation. For example, there is no point in asking people who use services what they think of the service and what they think should be done about it if one does not give clear and explicit responses to their suggestions. One does not have to do what they suggest, but what drives people around the bend is feeling they were not responded to. It may not be possible to do some things, but 90% of people can deal with that if the reason is explained. They cannot deal with the apparent fact that their well thought out comments disappear into some miasma and are never responded to. That is important.

I am taken with the willingness of the report's authors to see mental health in terms of biological, psychological and social needs and the need for an integrated care plan. I am worried that the report unintentionally presumes a single model of society based on everybody having a family within which they can be cared for. One of the fundamental changes taking place in every Western country is individual isolation. We will catch up on this as we have with all the other problems of success. I am not nostalgic for the Ireland of the past. For most people it was a dreadful country and for many it was not even a country in which they could live. However, I believe there are problems of success, one of which is individual isolation. Some 42% of the adult population of the United Kingdom are now living alone. It is not possible to base a model of service on the presumption of a supportive family. To a degree, the recommendations of the report are most welcome. However, to coin a phrase from the report, it needs to integrate with the way society is as distinct from an idealised model.

For instance, one of the consequences of our prosperity is that voluntarism is declining, not because people are less generous, but because people who previously had no such opportunity now have access to a paid job, which automatically means that the number of hours in their lives available for other matters is reduced. Therefore, we cannot presume that NGOs and voluntary groups, which are cited in the report as being partners, will continue to exist in the form in which they used to, as they may no longer have the membership and support to do so.

Nobody would dispute the value of specialist multidisciplinary teams. In a team involving a psychiatrist, a psychotherapist, a psychologist, an occupational therapist and a nurse, it is extremely important that the caseload of each matches. It is not practicable to have a psychiatrist whose caseload would be, let us say, 20 patients per week while the psychologist can only handle five, because he or she needs more time. This would result in dreadful mismatches. We must work out the issue of the time involved in dealing with such cases. It cannot be just one individual. The whole structure of a multidisciplinary team providing services to individuals must be based on an agreed hours allocation and not just on people. While one body can formulate policy, resources need to be available to provide a service. Engineers would refer to a critical-path analysis being important. It makes no sense to have a succession of service providers with one in the middle who, through no fault of his or her own and through no negative intent, causes a backlog. It is important that managers in particular listen to this.

I am concerned about the role of primary care, particularly the role of GPs in a country that is short of them. My GP has not needed to deal with psychiatric illness on my part, whatever about anything else he has needed to deal with. It is unreasonable to believe that he would give the amount of time to which we would aspire.

While I am not being sarcastic, it is a pity that the executive summary of the report contains no reference to its recommendations on services for the homeless. It does not help one to believe that it was a real focus. The proposals for services for the homeless reflect an excessively optimistic belief that somebody else will provide housing for homeless people. If this happened, of course many issues would be solved. However, we cannot get away from the fact that we have a housing crisis.

It is not possible to deal with psychiatric services for homeless people in a community of which they are not part. To a degree the recommendations in pages 143 to 147 are posited on the assumption that adequate housing will be available for homeless people. I have no reason to believe this will be the case. While there is an aspiration that Dublin will have no homeless people by 2010, I am not at all convinced. If that were achieved it would simply mean that nobody was sleeping on the streets. It is very difficult to provide service in the community for somebody living in the crowded and temporary conditions of a night shelter. The submission made by the Simon Community, with its very specific proposals for services for homeless people, needs to be fleshed out.

Previous attempts to restructure psychiatric services ended up with large numbers of psychiatrically-ill people on the streets. Almost paradoxically, the lack of adequate services and provision of supported housing for homeless people means that beds in acute psychiatric hospitals are often being used improperly by homeless people who, literally, have nowhere else to go.

The Simon Community's submission contained the hair-raising story about the person who, having been discharged from a hospital, arrived at a Simon hostel with an intravenous drip still in place. All large organisations make mistakes. However, fundamentally they are holding up beds because they have nowhere else to go. If they are discharged improperly they will simply be recycled back in. A disproportionate number of homeless people end up returning again and again to acute psychiatric hospitals.

The report contains the bones of a wonderful service. We need proper management by people who are prepared to manage in terms of what is right and not what is easy. We also need proper structures for the multidisciplinary teams. We need to continue to identify niches in the community, for example, homeless people and those who are both mentally ill and have substance abuse problems. For each of those a very specific service needs to be established, supported and maintained, even when money might become scarce. It is very easy to cut back on services for those living on the streets, as they will hardly be parading to Leinster House or voting in the next general election.