Phil Prendergast (Labour)

I thank the Minister of State for coming to the House. I have a somewhat different story for him and would like to make a few observations. It is my belief that A Vision for Changeis being abused by the Health Service Executive. It is supposed to be the blueprint for the future of our mental health services but it is being used as a type of propaganda tool.

My experience to date in Tipperary is that the HSE south has no intention of following A Vision for Change, a conclusion I have drawn from the untruths it tells the Irish public, more detail of which I can provide for the Minister of State. The Minister for Health and Children, Deputy Harney, and the Minister of State, Deputy Moloney, are not taking responsibility for this issue and are allowing themselves to be treated as HSE salespersons. It has become obvious at this stage, in the context of the Tipperary mental health services, that the Minister has taken on the role of selling HSE ideas to the public.

I would like to deal with the decision to close the 49 acute bed unit on the general hospital campus in south Tipperary as announced on 12 January. I would like to know the Minister of State's input into that decision-making process, which appears to be non-existent given his detailing in regard to how the decision was arrived at. I would like to know what input the Minister of State had in that decision and the status quo in this regard.

I met and received a briefing from Amnesty Ireland who has a number of wide ranging concerns in regard to A Vision for Change, some of which have been raised by previous speakers and which I will not repeat. I would like to know how many community health teams are in place as there appears to be a discrepancy between the number given by the Minister of State and the actual number in place. Perhaps the Minister of State will clarify the position in that regard and in regard to how many children's teams are in place. Children continue to be admitted to acute psychiatric adult wards and there are waiting lists in almost every HSE area of children awaiting assessment by psychologists and psychiatrists. The staffing levels in mental health services continue to be 50% below what is required. These figures have been supplied by Amnesty Ireland.

One fifth of what is envisaged in A Vision for Change has a cross-departmental element to it. This creates difficulty because co-ordination of mental health issues across the Departments of Health and Children and Justice, Equality and Law Reform and the SPCs, in terms of housing and social policy and how people are rehoused and taken care of in the community, is a big issue.

On the decision to close the acute unit in south Tipperary, an issue we have previously discussed with the Minister of State, the option appraisal document is three and a half pages long and was presented to the hospital executive at South Tipperary General Hospital as being the process by which this decision was arrived at. The document, entitled Proposal for the future of St. Michael's Unit Clonmel, states:

This paper sets out some of the background of St. Michael's Unit and puts forward the number of different options with regards to the future. [Background] St. Michael's Unit is a single-storey acute adult inpatient facility built in (?) and has 49 beds across two separate wards. There is a small high dependency unit (more detail ? seclusion room suite). It has an ECT suite and (? Fulfilling the national standards). Attached to the ward area a variety of offices to accommodate nursing and medical staff. Outpatient clinics are held here and in more recent years it has functioned effectively as an emergency drop-in facility (expand detail). A variety of Mental Health Commission reports have highlighted many of the shortcomings of this facility both in terms of physical structure, access to outside space and to meaningful daytime occupational and leisure facilities. It has been felt that these do not meet the requirements of a modern inpatient psychiatric facility. Additionally these reports have highlighted or suggested outdated standards of care or practice, possibly related to the association, with an older long stay institution next door. [He refers to St. Luke's which we all agree must close.] There have been issues with inflexible rostering and a lack of continuity of care. There appears to have developed a culture of risk averseness and in common with many other units significant problems with a population of people with co-morbid psychiatric and alcohol and polysubstance misuse problems. There have been significant attempts to address these problems including a St. Michael's Unit Group formed some years ago to look at the integration of two wards and setting standards for the unit. The development of an out of hour's service whose intention was to decrease admissions and more recently a Bed Management Group. Despite this and many other efforts the unit continues to be occupied at above 100% of its capacity and on leave beds are used to accommodate emergency admissions.

St. Michael's Unit for 40 years has admitted patients from the North Tipperary Sector and this amounts to approximately 40% of its bed capacity. Attempts have been made in the past to reprovide for the inpatient needs for North Tipperary patients but without success.

[Limerick, which is supposed to take these patients, cannot accommodate them.]

There are now significant challenges ahead in meeting the needs of the local population for their inpatient and community care including the necessary resources in line with Vision for Change guidelines and external imperatives such as the European Working Time Directive (EWTD) for Junior Doctors which needs to be implemented forthwith.

He then names two personnel, whom I will not name because that would not be correct before stating:

...please add in additional significant headline difficulties. You may want to also add in some strengths that say something like, "despite these difficulties staff have managed to carry on working in these very difficult circumstances with a high degree of commitment and effort").

Option One

Do nothing.

This is probably not an option as allowing the current state of affairs to continue would be unfair and would continue to ignore the inpatient care needs of the local population in the current physical environment.

Option Two

Redesign and refurbishment of the wards on the existing site including creation of an appropriate locked ward facility with appropriate seclusion facilities.

This would probably entail a reduction in the number of beds and reproviding for North Tipperary patients elsewhere. Given the physical nature of the site this is likely to be expensive in terms of capital costs and would not necessarily solve the practice issues referred to above. Equally redeveloping this site would mean there were too many acute inpatient beds for the population of the expanded directorate of Carlow/Kilkenny/South Tipperary (220,000 - 88,000 for South Tipperary). A bid for funding for such capital development would be in competition with other community capital development, which would be more in line with the modernising of mental health services as set out in the Vision for Change strategy.

Option Three

A new mental health facility build either on new site or current site. This option could include provision for North Tipperary patients or not.

While this may be attractive politically it would still suffer from the same problems as the previous option in that it would be competing for capital funding with community-based facilities and services and out of keeping with the total number of acute beds needed for expanded directorate catchment area for Carlow/Kilkenny/South Tipperary.

Option Four

Closure of St. Michael's Unit at end of 2010/first quarter of 2011.

The essence of this proposal is that robust alternatives to admission were implemented in the community in South Tipperary prior to its closure. North Tipperary patients would have to be accommodated within their own expanded directorate catchment area. Admissions for South Tipperary patients would need to be approximately halved and be accommodated in the Department of Psychiatry wards in St. Luke's Hospital, Kilkenny.

The advantages of the reprovision of inpatient care needs for South Tipperary patients with the closure of St. Michael's would be:

1. Release of resources to fund more modern community-focused services for South Tipperary, North Tipperary and Carlow/Kilkenny.

2. A provision of a higher standard of physical inpatient environment in Kilkenny.

3. A removal of the requirement to implement EWTD for Junior Doctors in South Tipperary.

4. Increase capacity of mental health staff to concentrate on community service provision, most notably Consultant Psychiatrists who would not be required to provide inpatient care for their patients while accommodated in Kilkenny, thereby releasing them to focus on community service development and community provision (anything else).

Disadvantages

1. Local/political concern about change in provision of services.

2. Resistance from staff groups.

3. Travel to and from South Tipperary to Kilkenny for patients and their friends/relatives.

4. Difficulties in implementing changes in mindset/work practices e.g. change in consultants' job remits.

5. Significant cost of funding adequate community resources to implement this option fully, safely and effectively.

6. Potential for increased numbers of incidents in community.

7. Concerns and possible resistance from other chief stakeholders, e.g. Gardaí in cases of for instance, involuntary admissions, assisted admissions etc.

8. Significant difficulties for Limerick or Mid-West expanded catchment area to reprovide for North Tipperary inpatient needs, (any others?)

This is the option appraisal document which led to the announcement of the closure of 49 acute beds in south Tipperary and I cannot believe the Minister of State signed off on this because nowhere in the document is what should be in an option appraisal document. I have an example of what should be in such a document and it provides for consultation. There was no consultation with the nursing staff, psychiatrists, the staff running the hospital or the patients and this decision was announced on 12 January.

Dr. Kelly continues:

In order for this option to be feasible a number of essential requirements would need to be implemented:

1. Creation of a project team to oversee reprovision programme - January 2010. This can be achieved within existing resources and consist of essentially an expansion of the project team overseeing the closure of St. Luke's Hospital.

2. Effective engagement and communication strategy for all key stakeholders both internal and external to the organisation within existing resources.

3. Development of home based treatment services comprising of 0.5 WTE consultant, 1WTENCHD, 1 CNS, 10-12 WTECMHNs, 0.5 WTE psychologists, 1 WTE social worker, 1 WTE O.T., 3-4 WTE healthcare workers, 1 WTE admin support (see appendix for model).

4. Team base for home treatment team? St. Michael's Unit or exiting community facility.

5. Provision of training programme.

6. Crisis house in community.

7. (any other central requirements?)

This document is dated 6 January 2010.

The Minister of State referred to the construction of the new unit in Letterkenny, the construction of a community nursing unit in Clonmel and the closure of St. Luke's Hospital but he did not mention the closure of St. Michael's unit on the general hospital campus. Perhaps he will clarify the decision. If the appraisal document I read into the record constitutes a decision-making process that does not involve a member of staff working in the facility or providing services, will he clarify how the HSE is doing its business and how the people of south Tipperary will be treated?