John Moloney (Laois-Offaly, Fianna Fail)

I express my thanks to the Leader, Senator Cassidy, and to my colleague, Senator Phelan, for their welcome. Coming into the House for the first time as Minister of State, I am pleased the issue is related specifically to the area of mental health. In that regard I thank Senator Boyle and Senator de Búrca. It is not unorthodox for either Senator Boyle or Senator de Búrca to introduce this Bill during Private Members' time. The area of mental health and well-being is an issue to which no party on its own has all the answers. A number of the points raised, including those by Senator Fitzgerald, are relevant and forward-thinking and it is up to us to embrace that.

My job in the Department is not to come to the House and stamp a political party's approval on any proposal but to recognise that in moving forward the area of mental health and well-being there are areas we must re-examine and there is room for amendments. The Bill is timely because the officials in the Department are engaged in drafting amendments to the Act. This Bill is timely but it was never meant to suggest to the parties in Government that it had all the answers. It is fair to record also that the need for the amendments was identified in the review of the operation of the Act. That review is ongoing. That is not to suggest that the review will go on indefinitely. It is quite immediate.

There are several views on aspects of ECT. I welcome Mr. John McCarthy and other people who have met me privately. They have quite trenchantly described to me their areas of concern. I will take on board the concerns of people, matched with the advice from other sectors in the psychiatry profession.

We are prepared to listen to all the groups as we move on with this debate. I agree with Senator Fitzgerald's suggestion that the Joint Committee on Health and Children should be the forum for bringing in people such as the Mental Health Commission, the various advocacy groups, representatives of the psychiatry profession, to deal with the issue of ECT. It is also timely to state that this information is being collated. It will be important to study the results which will show the number of patients who have presented, both voluntarily and involuntarily for this treatment. This data should be studied in advance of any meetings of the Joint Committee on Health and Children.

I also wish to recognise other points made by Senators, such as the issue of the stigma attached to those who present with mental health difficulties. If I am asked for my views and the policy of my Department, my priority as Minister of State will be to implement change and I hope I will be in the position long enough to do so. I refer in particular to the area of the stigma attached to mental illness. I know of many people who will say they are reluctant to present for treatment because it is often given in the old psychiatric hospital system.

I can state with a certain background knowledge that many people have suffered from the disease of alcoholism and related depressive illnesses. I have no problem saying that my father suffered with the disease of alcoholism. He made no bones about it. In the 20 years when he was on the dry, he took time to try to explain to people the very sensible attitude that alcoholism is the same as any other illness and it was clearly up to the State to provide facilities to ensure that people withdrawing from that illness could seek treatment. Unfortunately, in the 1960s and 1970s, the only places available, unless one had private money, were in the local psychiatric hospitals.

I wish to put down a marker for my time in the Department that I want to see support come from the Oireachtas Members throughout the State. I have already asked for an audit of all the State's assets connected with psychiatric hospitals and attached lands. Members of the Oireachtas must prove our bona fides in the constituencies. The funding from securing those assets will go directly back into mental health. If people have concerns that this funding will be swallowed up in some other part of the HSE, I can assure the House that this funding will be specifically used for the upgrading and modernisation of mental health facilities in the country.

The report of the Mental Health Commission recommended that acute psychiatric care units should be located throughout the State. People should be properly housed in psychiatric facilities that are deemed proper for their care. Adolescent patients are currently housed in hospitals that were built not in the last century but in the one before that. I am making a policy commitment to remove the stigma by inviting four or five people from each county who have been successful in the arts, politics, drama or sport, who have presented with mental health difficulties, have been properly treated and are back in the workforce to speak about their experiences. This would be a start in removing the stigma.

I attended a conference in Brussels last week, as did John McCarthy, who is in the Visitors Gallery. I heard the most telling speech I have ever heard from the former Norwegian Prime Minister. He stated that while Prime Minister he had suffered from a depressive illness. He kept this to himself for quite some time but he then realised he could no longer do so. When he told his advisers that he needed to make a statement about his illness his officials beseeched him to say he had some other illness but he disagreed and told the public about his illness. As a result of his public announcement about his difficulties, mental health treatment in Norway moved on years beyond where we are today. I hope we can move on. I have set out my commitment to work to remove that stigma, to work to modernise the mental health service by providing facilities. Senator Fitzgerald was a member of the joint committee when we produced the report on the high levels of suicide. We made 64 recommendations, all of which tie in with the Reach Out programme established by the Government.

I wish to assure the House that the Government is firmly committed to the development of our mental health service and to the protection of people with mental health difficulties. At the end of January last, the office for disability and mental health was established with a remit to bring about greater collaboration across the public service on issues relating to disability and mental health. This office is cross-sectoral and will deal with different Departments such as the Departments of Education and Science, Justice, Equality and Law Reform, Enterprise, Trade and Employment and Health and Children. The office will promote and encourage an integrated "whole-of-government" approach in progressing the Government's agenda in this area, and will make the political commitment to disability and mental health a reality. In response to Senator Fitzgerald, it is clear the commitment can be challenged when we hear of a reduction in funding of €25 million and I have to accept what she says. It is up to the Department and the senior and junior Ministers to establish the reason the HSE removed the €25 million and I have requested this information. It is also necessary to conduct an audit of where the effects of the reduction in funding of €25 million will be seen. We must also ensure the funding initially allocated remains intact. I have requested a meeting with the HSE to seek answers to those questions and I expect this meeting will take place in the next few days.

In recent years there have been significant and very welcome developments within mental health services in Ireland with the launch of A Vision for Change, the report of the expert group on mental health policy in January 2006 and the full implementation of the Mental Health Act 2001. We cannot move on A Vision for Change unless we have the capital funding to do so and this will involve the realisation of the asset value into proper modern facilities. A Vision for Change represents a seven to ten-year action plan for the development of a modern, high quality mental health service which places the person at the centre. The future direction and delivery of all aspects of our mental health services are covered in the report.

The Mental Health Act 2001, which was fully implemented from 1 November 2006, is unquestionably the most significant piece of mental health legislation in Ireland in the past 60 years. It provides improved safeguards for people with mental illness and ensures the protection of the rights of people who are admitted involuntarily for care and treatment. This is the kernel of the issue proposed in this Private Members' Bill.

All involuntary detentions are now automatically reviewed by an independent Mental Health Tribunal. The review is independent, automatic and must be completed within 21 days of the detention or an extension order being signed. This brings Irish mental health legislation into line with the European Convention for the Protection of Human Rights and Fundamental Freedoms.

Part 2 of the 2001 Act has extensive provisions governing the use of involuntary admission procedures and is acknowledged as containing a high level of protective measures in relation to patients' rights. Members will gather from my speech that the overall theme is one of protection. We must work towards and agree on the degrees of protection involved and that is why I am suggesting, particularly to Senator de Búrca, that the amendments will quite properly take into account most of the views that have been expressed here today. I do not want to sign off on that as there is a long road to go but we are prepared to accept such amendments. I am not here to refuse Opposition amendments, nor to ignore the Private Members' motion. I want to establish clearly that it is a matter of us working together towards producing a Mental Health Act of which we can be proud and, more importantly, a legislative measure with which patients and their families can be satisfied.

The discussion here regarding a proposed amendment of the Mental Health Act is timely as my officials are currently engaged in drafting amendments to the Act. The need for these amendments was identified in the context of the review of the operation of the Act which was undertaken by the Department of Health and Children and laid before the House in May 2007. However, while amendments on the lines proposed are not envisaged at this stage, I am here this evening to listen to the views expressed. I am open to considering ways in which we can further improve our legislative protection for people with mental health difficulties. I see that as being the basis for the motion before the House also.

Our current legislation places a much needed focus on the human rights of people receiving care and treatment on an involuntary basis, and we must be careful at all times to ensure that respect and the promotion of the human rights of the service user continue to be the principles underpinning any legislative developments.

The proposal before us seeks to amend the Mental Health Act 2001 concerning two particular forms of treatment, psychosurgery and electro-convulsive therapy, otherwise referred to as ECT, which may be administered to patients who are detained involuntarily under the terms of the 2001 Act. First, let us consider the proposal to delete section 58 of the Mental Health Act 2001, which deals with psychosurgery. Section 58 currently prohibits the carrying out of psychosurgery on involuntary patients, except where the consent of the patient in writing has been given and the procedure has been authorised by a mental health tribunal. Section 58 is clearly a protective provision therefore.

If the proposed amendment were accepted, the administration of psychosurgery would not be prohibited; rather the legislative protection for the patient in terms of requiring his or her consent, and the authorisation of the procedure by an independent mental health tribunal, would be removed. That is where the difficulty arises. The proposed amendment, in effect, reduces the protection for persons suffering from mental illness and its acceptance would undermine our achievements over recent years in securing better protection for such vulnerable people. The place to tease out this matter further could well be the Joint Committee on Health and Children. Psychosurgery is a procedure that is rarely, if ever, used. Nonetheless, it is important that provisions relating to psychosurgery should be retained in our legislation in order to protect involuntary patients against the arbitrary use of the procedure in the future.

I now turn to the second element of the proposal, which seeks to amend section 59 to remove the provision which allows ECT to be administered to an involuntary patient without his or her consent. Our current legislation requires that a patient must consent in writing to the administration of ECT. However, the legislation provides that where a patient is unable or unwilling to give consent, the treatment may be administered if it has been approved by the consultant psychiatrist responsible for the care and treatment of the patient and authorised by another consultant psychiatrist.

There are of course diverging views both within and outside of the psychiatric profession on the necessity and-or efficacy of ECT. Clearly, that is the issue with which we are trying to deal. However, it remains a recognised treatment for severe mental illness and is sometimes used to treat persons with severe depression who do not respond to drug treatment.

A review and meta-analysis which was published in the highly respected medical journal The Lancet in 2003, concluded that ECT is probably more effective than drug therapy. Of course it can be a feature of severe mental illness that a person's judgment may be so impaired that he or she lacks insight into his or her own condition. Where a person is involuntarily admitted under the provisions of the 2001 Act for treatment that he or she might not otherwise receive, it is incumbent on the State and treating clinicians to provide that person with the most effective treatment for his or her condition. A duty of care is expected from the State for people who have been admitted involuntarily, and that is the reason for that provision.

If the treating consultant psychiatrist is of the opinion, based on his or her clinical expertise, that ECT is the most effective treatment in the circumstances, the law should make provision for the administration of that treatment to those who are not in a position to give their consent, within the necessary safeguards of the 2001 Act. It could be argued that to do otherwise would be in contravention of the State's duty of care to the involuntary patient. If somebody is admitted involuntarily, where does the duty of care begin or end? I believe the State has to exercise that duty of care.

During the course of the review of the Act which was undertaken by my Department and completed last year, some submissions suggested that the reference to a person who is "unwilling" to consent to ECT should be deleted from section 59. In other words, where capacity to consent exists, any refusal to accept treatment should be respected, and this right respected by law. In principle, I would accept this suggestion, but this matter cannot be dealt with in isolation. Legislation is being prepared which will take into account issues that arise in this debate. The matter will not be parked or shelved because it is part of the ongoing process of arriving at legislation that will be well accepted.

Any amendment of the Mental Health Act on these lines — for example, to delete the word "unwilling" from section 59 — would have to be undertaken within a supporting framework of legislation defining legal capacity. The Office for Disability and Mental Health has already raised this matter in the context of the development of new capacity legislation by the Department of Justice, Equality and Law Reform. I can assure the House that it will be considered further in that context. This aspect defines the importance of the Minister of State with responsibility for disability and mental health. It is a cross-departmental issue that requires continued action, not least under my Department's aegis.

The ethos of the Mental Health Act 2001 was to provide a modern framework within which people who have a mental disorder and require treatment or protection can be cared for and treated. The Act provides mechanisms by which the standards, care and treatment in mental health services to the most vulnerable of all can be monitored, inspected and regulated.

In this regard, the Mental Health Commission published rules on the use of ECT in November 2006 and the inspector of mental health services monitors compliance with these rules on an annual basis. While compliance is important, I take the point made by some Senators that it is also important to have the data to hand, and they are currently being prepared. The rules require that at the conclusion of a programme of ECT, an ECT register is completed for each involuntary patient and a copy placed in the patient's clinical file. The administration of ECT without consent must be recorded in the patient's file and a copy forwarded to the Mental Health Commission, which is an important safeguard. These rules are kept under periodic review by the commission and can be revised as required. Any review of the rules governing the administration of ECT should ensure international best practice continues to be taken into account.

The Mental Health Commission recently published a review of the operation of Part 2 of the Mental Health Act 2001, as required under Section 42 of the Act. The report noted that stakeholders in the mental health services have participated in a significant programme of reform in recent years and that commencement of Part 2 of the 2001 Act has brought a greater level of openness to mental health services in Ireland.

I thank those contributing. I especially thank Senators Boyle and de Búrca for putting this on the agenda of the House. I say that genuinely coming from a position, as we all do, of trying to improve mental health services. It is fair to point out that there have undoubtedly been great strides taken in the development of mental health services in Ireland in recent years, particularly in improving the legislative protection of persons with mental illness.

While I have reservations about deleting section 58 on psychosurgery, further consideration of these provisions in the Act concerning consent to treatment is appropriate and will be progressed in the context of the development of capacity legislation.

I want to confirm that we are saying "Yes". On the concerns raised, we are preparing amendments. In the context of the capacity legislation, it gives us the vehicle to take on board what the Senators are saying. I also see the tremendous sense in properly and openly debating the issue at Oireachtas Joint Committee on Health and Children level, particularly by way of bringing in experts who will voice their positions for or against. It will also deal with the issue of ECT, especially for elderly patients who refuse to eat or drink. It must be underpinned by the Government's commitment by way of a duty of care.

I thank the Senators for giving me this opportunity. I again issue the invitation that we will sit down in September or October with all the Members who represent constituencies where there are the older facilities to see if we can come up with a common programme, rather than a Government programme, as to how we can transfer the assets to modern facilities. I invite everybody to participate in that. To my mind, that is the way to move forward. Not everything will be resolved by way of new buildings. It is equally important to have the back-up professional staff. I am prepared to take all the advice given to me, particularly by the advocacy groups and, more importantly, by the Mental Health Commission.