Kathleen Lynch (Cork North Central, Labour) | Oireachtas source

I welcome the opportunity to discuss mental health policies and services for children and adolescents. The promotion of positive mental health and well-being in general is important to us all. For many reasons and in many respects, mental health is a complex and emotive issue. It is encouraging that in my time as Minister of State, I have generally found that Members of Houses have taken a non-partisan approach to improving the area of mental health and implementing A Vision for Change, which is a widely supported policy. While I remain as open as ever to constructive criticism or realistic suggestions, I ask for objectivity and, above all, the best interests of service users to remain paramount today.I welcome the increased focus on mental health in recent years. The service was, with some justification, tagged with Cinderella connotations, primarily due to historic neglect and under-investment. In particular, the question of developing mental health services for young people, coupled with a real appreciation of changes required to meet evolving need, was only highlighted by an ever-widening gap against non-delivery of both agreed policy and best international provision. This Government has, therefore, prioritised investment in mental health, including community and mental health services, CAMHS, and the HSE has been steadily implementing change on the ground. Given our starting point, and the many variables that influence real change, I have always said that this can only be achieved on an incremental basis and that there is no magic wand solution to developing the modern service we all desire.

Reforming mental health has led to much needed additional investment, but it also requires new approaches to enable the capacity of our system, in terms of new delivery models, to realise a common vision. This ranges from overcoming staff recruitment and retention issues to rebalancing services at local level between acute and community-based care in order to achieve the objectives of A Vision for Change.Until relatively recently, mental health was an issue hidden away, reinforced by high walls of stone and the higher walls of stigma and attitude. Fortunately, our culture is changing to one of greater sympathy, understanding and tolerance. Most importantly, better treatment options for the individual now exist to the point that recovery is much more achievable, including for the most severe cases requiring inpatient care. It is in this context that the HSE mental health services nationally has set about tackling the challenges of re-orientating from a hospital and bed-based focus to developing structures and processes required for enhanced community provision in line with A Vision for Change. Notwithstanding the difficult financial position we faced, the Government nonetheless prioritised the development of our mental health services. The genuine implementation difficulties we face on the ground in some areas, and which I have often acknowledged, do not primarily relate to a lack of money. It is, as I have indicated equally often, more a question of change catching up with the funding provided. Overarching factors coming into play on CAMHS range from securing the type of specialists we need in the right place to increasing demands on our CAMHS system in recent years.

The Government has provided €125 million ring-fenced funding for new service initiatives. Many of the initiatives undertaken to date, or planned, have a clear dimension to improve community and mental health services on the ground. This involves new posts and a more integrated client-centred service. Overall, we have provided funding this year of some €790 million to the HSE for mental health, including the €35 million I secured in the last budget. Every region has benefited from additional consultant psychiatrists, social workers, occupational therapists, nurses or allied professional staff. We have approved more than 1,150 new posts since 2012. Around 260 of these were specifically designated for CAMHS of which the majority are now in place or well advanced through recruitment.

At the end of 2014, despite staff turnover and recruitment difficulties, there were some 520 staff in HSE community and mental health services. Actual clinical staffing of CAMHS teams increased by 47, or around 10%, from September 2013 to December 2014. This is in a context of wider staffing difficulties elsewhere in our health system. A further 100 new posts in 2014-15 will improve CAMHS resources by around 20%. I acknowledge that issues such as recruitment, retention or staff mobility between regions present particular difficulties. It should be remembered also that the child and adolescent service is without doubt one of the most challenging work environments across our entire health and social care system. I will be the first to admit that the pace of acquiring additional staff to strengthen community teams has been slower than desired, but steady progress is being made.

The HSE mental health division, MHD, is committed to ensuring that all aspects of CAMHS are delivered in a more consistent and timely fashion across all regions, including the key issues of assessment and access. Therefore, a child and adolescent mental health services improvement steering group was established last year, together with a dedicated project group to improve key performance indicators for CAMHS nationally. One of the primary objectives is to develop a standard operating procedure for both inpatient and community and mental health services. The purpose of better standardisation is to ensure that delivery of services is carried out in a more consistent and transparent manner across the State; the care and treatment offered reflects the identified clinical needs of the child; and those who access treatment programmes for similar clinical presentations will receive a level of clinical care consistent across all child and adolescent services. There is clearer direction and information for CAMHS teams, and other partner services, about service provision.

These objectives are being underpinned by various new initiatives which the HSE hopes to advance this year to promote robust preventative and quality mental health services for all children and adolescents. Examples include a CAMHS community forensic team to work at national level with at risk children accessing mental health services and known to Tusla and the juvenile justice system. This team will be a precursor to the new ten bed CAMHS forensic inpatient facility being developed as part of the new forensic hospital in Portrane, due for completion in 2018. A clinical care eating disorder programme will design pathways of intervention for both children and adults with moderate and severe eating disorders. A new eight bed inpatient unit will also be developed in collaboration with the national children's hospital. There are proposals to expand the day hospital model for adolescents in need of intensive mental health service supports in the geographic areas of the north west and south east as well as other provincial sites. Funding will be provided for Headstrong to provide jigsaw programmes in ten sites to support young people's mental health, and further access to psychological therapies, both psychology and counselling, in primary care for young people who would otherwise be referred to the more specialist CAMHS care.

In addition to these planned initiatives, the National Office for Suicide Prevention currently funds approximately 40 agencies to provide health promotion programmes and support to children, adolescents and adults. There is continued investment in health education campaigns such as Let Someone Know and Your Mental Healththat promote positive mental health, and stress the importance of talking and listening.

The provision of inpatient beds and community mental health services are integral components of a range of services required to appropriately meet the needs of young people with mental health issues. Interventions are provided, in the first instance, through community mental health teams and, if required, access to relevant inpatient services is also available. Nationally, inpatient bed capacity has increased from 12 beds in 2007 to 58 at present - 26 in Dublin, 12 in Cork and 20 in Galway. This represents an increase of almost 400% in the number of beds over eight years. A new purpose built 22 bed child and adolescent inpatient unit located on the grounds of Cherry Orchard Hospital is due to be completed shortly and to become operational towards the end of the year. The existing 14 beds in the current temporary facility will transfer across, thereby giving a net increase of eight beds in the facility. The HSE intends also to open an additional eight beds, currently closed, in the Eist Linn Unit in Cork when current staffing recruitment issues are resolved. Overall, the Health Service Executive is targeting a total operational capacity of 74 beds nationally in 2015 which, if achieved, would be a significant increase in capacity.

It is a priority for me to address the issue of children and adolescents having, at times, to be admitted to adult acute units. While these inappropriate admissions have decreased continually in recent years, there is room for improvement. Figures for 2014 indicate that there were 89 admissions of children to adult psychiatric units, with the majority being, voluntary and involving parental consent. Approximately 85% of these admissions were 16 to 17 year olds, with a third of these discharged within two days of admission, and two thirds within a week.Some of these admissions relate to a crisis situation where no adolescent bed is immediately available. Some may only last for a few hours - to help cope with a short mental health episode and where the practical solution is to temporarily place the child in an adult unit. Distance to the nearest CAMHS inpatient unit can also be a factor when immediate clinical assessment and treatment may be an inevitable requirement. In some cases, the presenting clinical needs of the young person, who may be nearly 18 years of age, may also have to be taken into account. The HSE has recently refocused various operational initiatives to achieve improvements in this area in 2015. This includes priority actions to enhance performance and national oversight to reduce admissions of children and adolescents to adult units to only 5% in 2015. This is an ambitious and challenging target, notwithstanding the increased funding available for child and adolescent mental health services. I firmly believe, based on my direct experience of visiting centres, that there is still scope to ensure better use of existing CAMHS beds in some local units and I am strongly pushing this with the HSE.

Central to an improved CAMHS service is the need to address waiting lists. I would like to take this opportunity to correct statements made during the course of a Topical Issue debate on mental health in the Dáil on 22 April last. In the first instance, Deputy Boyd Barrett alluded to the Minister, Deputy Varadkar, that I may have misled the House recently by indicating that staffing levels in child mental health services were filled up to 80%. It may be a question of misinterpretation by the Deputy but in a written reply to a parliamentary question to him on 16 April 2015, I stated that since 2012, around 260 new posts have been allocated specifically to CAMHS and approximately 80% of CAMHS posts were in place at the end of March 2015. I was, therefore, referring clearly to 80% of the 260 new posts approved to date by this Government, and not to all CAMHS posts in the HSE. Second, Deputy Keaveney stated in the course of the same debate on 22 April that 3,000 children this year will wait 12 months for a CAMHS appointment. However, in a reply on 20 April last from the HSE to the Deputy, it was stated quite clearly that at the end of January 2015, the total number of children on the CAMHS waiting list was just under 3,000. Furthermore, of these,1,200 were seen within the first three months. Some 470 children were waiting 12 months or longer and not the 3,000 as indicated by the Deputy. I have always shared the common view that it is highly unacceptable for a child to wait longer than 12 months to be seen by any of the 62 CAMHS teams. I have also said that misinformation does no one any favours, particularly parents worried about their child's mental health. The reality is that a number of factors influence the complexity and provision of individual CAMHS cases. These include at local level the number of emergency cases presenting, CAMHS capacity and administrative supports or links with related services such as Tusla or the National Educational Psychological Service, NEPS. These in turn can impact on discharge rates, increased numbers on waiting lists or longer waiting lists for routine assessments. In respect of CAMHS waiting times, I wish to highlight that all cases are triaged and urgent cases are seen as a priority. Many of these urgent cases are seen within days. In 2014, 55% of children who were seen were seen in under four weeks. This is against the backdrop of an increasing number of referrals to the service, including 16 year olds and 17 year olds.

The CAMHS waiting list nationally currently stands at around 3,000, representing a 10% increase in demand over the corresponding period last year. At my request, the HSE recently commenced a specific and urgent validation exercise on the list to clarify if all children are being referred to the appropriate specialist psychiatric service. It should be remembered that mental health problems are not the sole remit of CAMHS. The new level of validation now being undertaken will help to determine if all children are being referred to the appropriate specialist psychiatric service or if they actually need other services. There is some evidence that children are being referred to CAMHS due to difficulties in accessing less specialised services. In this context, the HSE is examining proposals to enhance related service provision jointly with primary care. This may involve a new early intervention initiative to allow some children and adolescents to be seen by a more appropriate service. Those assessed as needing CAMHS treatment could then be expedited.

A number of issues are of relevance in the context of the ongoing validation exercise. Despite the increased rate of referrals, the CAMHS teams nationally are achieving the targets set out in the HSE service plan. However, these targets are set against the backdrop of teams which need improvement, as I indicated earlier. The first phase of the validation is concentrating on those waiting for more than 12 months and will then move to those in the three month to 12 month waiting list category. The greatest possible focus is being placed on CAMHS referral sources such as general practitioners, child health services, NEPS and primary care services to help inform what operational improvements can be adopted in the future for the most appropriate referrals. While those with a co-morbid presentation, such as ASD with mental health issues would require a CAMHS service, others with general emotional difficulties may not require specialist CAMHS intervention and might, for example, be covered more appropriately by disability or primary care services. There are many examples of good work being carried out by CAMHS teams across the country and it is obviously necessary to extent this to all areas.

I would be the first to accept that while some progress has been made, we have some way to go to achieve the type of CAMHS we need. We owe it to our most vulnerable citizens - young, middle-aged and elderly - with mental health issues to keep working in partnership as politicians and administrators to change our laws and services for the better to meet their needs. However, it must be acknowledged that we are righting a wrong in this country that put mental health at the back of the queue for funding and reform until very recently.