Jim Daly (Cork South West, Fine Gael) | Oireachtas source

Only time will tell. I will enjoy the day that is in it because as time goes on the welcome may be somewhat lessened. We may get more adversarial but hopefully we will not. On a more serious note, I commend Senators on the quality of the debate I have listened to. It is no wonder the House is referred to as the Upper House because there was a very high standard of debate here today. I have been genuinely very moved and impressed by the quality and calibre of the speakers and the sincerity, collaboration and genuineness of their approach. I say "Well done" to each and every one of the speakers.

I congratulate Senator Freeman for taking on an issue as real and urgent as this one. It is something that means a great deal to many people. These are our most vulnerable citizens and we owe it to them to discuss in the Houses of the Oireachtas the issues that affect them and to be their voice. I say "Well done" to her for bringing this to the floor of the House. It is a very good day when we have conversations like this in both Houses and when we have discussed so freely and openly mental health and the challenges associated with it.

As the newly-appointed Minister of State with responsibility for mental health and older people, I am delighted to have the opportunity to respond on behalf of the Government to Senator Freeman's Bill. It is important to begin my remarks by saying that I fully accept that we must continue to do all that we can to reduce to the greatest degree possible the number of child admissions to adult psychiatric units. I do not doubt for a second that all Members of the House agree on that and on the proposals contained in the Bill. The debate on the Bill is not about whether we agree that we need to reduce these admissions, which is a given. What we need to consider this evening is whether the Bill can actually achieve the aim of reducing such admissions. Equally, we need to be mindful of any unintended consequences of the Bill. We must not allow our shared desire to reduce such admissions to reduce in any way the scrutiny to which we subject this Bill.

The Government is committed to reducing the number of child admissions to adult units further and, in that regard, significant progress has already been made. Such admissions were reduced from 247 in 2008 to 68 at the end of 2016. Of course, that does not mean the job is done. Again, I do not need convincing that we need to continue to do more to bring this figure down further. It is still 68 too many if they are inappropriately placed in care. My Department and the HSE are working hard on a continuous basis to improve the delivery of mental health services for children. These services have benefitted from the significant additional investment in mental health in recent years. The HSE's service plan for 2017 will further develop CAMHS as a priority, including better out-of-hours liaison and seven-day response services. Since 2012, around €140 million has been added to the HSE's mental health budget, which is an increase of around 20% between 2012 and 2017. The Programme for a Partnership Government also gives a clear commitment to increase our mental health budget annually, as resources allow, to expand existing services.

It is no secret that demand for services continues to exceed availability as evidenced through waiting lists for CAMHS. CAMHS is identified as a key service improvement project for the HSE and work has been ongoing to reduce waiting lists with a particular focus on those who have been waiting for more than 12 months. Some of the main contributing factors that are impacting on waiting times for CAMHS services are vacancies within teams as well as cases that are more appropriate to primary care and disabilities. There are well-publicised difficulties in recruiting certain categories of staff, including consultants and nursing staff. The HSE continues to make strenuous efforts to recruit such staff, including greater support for specialist training of consultants and the development of a nursing postgraduate training programme. The recruitment of 114 assistant psychologists has recently been approved by the Department of Public Expenditure and Reform, which is a significant step in reducing waiting lists for CAMHS. Introducing mental health expertise in primary care also has the potential to provide quicker access to mental health supports for families and children where difficulties have arisen and to prevent the development of more serious difficulties. The question that must be asked is how the specific legislative changes proposed in Senator Freeman's Bill this will improve services for children. As I have already said, we are all on the same side in wanting to reduce such admissions and the motives behind Senator Freeman's Bill are well intentioned. On the face of it, the Bill seems reasoned and proportionate but my Department has some concerns over the possible unintended consequences of the Bill and it would be remiss of me not to mention these. I believe these concerns need to be considered in more detail with Senator Freeman and other interested parties before the Bill advances to Committee Stage and I know the Senator agrees with me on this.

In light of this I welcome that Senator Freeman has agreed that the Bill not progress to Committee Stage before 31 October to allow time for my Department to continue to work with her on the Bill. As I am new on the job, I will take that opportunity to work with the Senator to add some finesse. We need to address the concerns, as none of us wants unintended consequences. We can debate those rationally but that does not take from the spirit of the Senator's Bill in any way.

The aim of this Bill, which is to allow for the admission of children to adult units in exceptional circumstances only, is already existing practice. The Mental Health Commission has a code of practice for the involuntary admission of children and section 2.5 of that document sets out the procedures that should apply in circumstances where it is deemed necessary that a child be admitted to an adult unit, including the need for the approved centre to have appropriate policies and protocols in place and age-appropriate facilities.

The code also puts an onus on the commission to review the number of admissions of children to approved centres for adults from time to time. The commission comments on this in each of its annual reports, as well as providing specific commentary in relevant approved centre inspection reports. These requirements are in place specifically to reflect the importance attached to monitoring such admissions where they are deemed necessary.

The commission also requires consultant psychiatrists to explain exactly why they have admitted a child to an adult unit. For example, in addition to setting out the reasons for the proposed admission, the consultant must outline the efforts made to admit the child to an age-appropriate approved centre and he or she is required to confirm that no bed is available in an age-appropriate centre. He or she must also explain what alternatives were considered to admitting the child to an adult unit and why these alternatives were not deemed possible. Furthermore, information must be given on the length of time the child is expected to remain in the adult unit and on the plans to place the child in an age-appropriate approved centre. Finally, the commission must be notified of all such admissions.

There is no doubt, therefore, that existing admissions must only occur in exceptional circumstances and all such admissions must be fully explained to the independent regulator. Putting existing practice on a statutory footing, however, presents a number of problems. For example, there are concerns over the requirement to put the term "emergency circumstances" in primary legislation. This phrase would have to be clearly defined, yet the word "emergency" by its very nature is difficult to capture in all circumstances. On the one hand if the definition is too literal, there is a risk that some children may lose out while if it is too general, there is a risk that any circumstances can be considered emergency circumstances.

Previous experience would suggest that referrals to the courts could increase and that they could be left to make judgments in cases which are not easily defined. While no one would deny that people have an absolute right to go to court, there is an onus on the Legislature to ensure to the greatest degree possible that the law is based on sound principles and is not easily open to differing interpretations. This concern is real and needs to be considered further.

Arising from the possibility that putting the term "emergency circumstances" in primary legislation may add greater uncertainty to the admissions process, another concern is that consultant psychiatrists may reconsider referring a child for inpatient treatment if an adult unit is all that is available at the time. This potentially leaves a patient with a high clinical need open to the risk of delayed treatment or possibly no admission at all. As legislators, we should not be tying the hands of the medical profession and interfering with the clinical process.

While the rationale behind the Bill, as stated by Senator Freeman, is clearly to end child admissions to adult units, paradoxically the Bill as currently worded would for the first time actually legalise the practice of admitting children to adult units albeit in emergency circumstances only. The question must therefore be asked if this will be seen as a sign that such admissions, now being formally provided for under primary legislation, will in some minds standardise this process. This is the opposite of what the Bill intends to achieve.

A comprehensive expert group review of the Mental Health Act 2001 was published in 2015. The group made 13 specific recommendations as to how our mental health legislation relating to children could be improved, including, for example, the recommendation that a stand-alone section of the Act should deal with children. In addition, the group recommended including in the legislation a list of child-appropriate guiding principles which would include, for example, that every child should have access to health services which aim to deliver the highest attainable standard of child mental health and that services should be provided in an age-appropriate environment wherever possible.

The group suggested that the latter recommendation be included in guiding principles that are intended to guide the interpretation of the Act rather than recommending that any specific reference to adult units be included in a section of the Act listing it as an absolute requirement. This is a key distinction for Senators to consider and I believe that proceeding on this basis offers a measured and considered approach to the issue of child admissions to adult units without tying the hands of the medical profession in clinical circumstances. I also think this suggests a way forward that Senators could see as a useful compromise.

It is also important to understand some of the reasons a child might be admitted to an adult unit. For example, such admissions may be deemed safer than referral to an adolescent unit located a considerable distance away, especially if drug or substance abuse is involved. In a small number of cases young people have been admitted to an adult unit due to their challenging behaviour and the impact that this may have on other young people in an adolescent unit. In other cases, the parents of the young person sought to have the admission to the local adult unit instead of a placement in an adolescent unit due to the distances that can be involved.

Quite a few issues relating to the text included in the Bill require clarification or amendment. Most significantly, it proposes amendments to section 14 of the Mental Health Act 2001. However, this section only deals with adults, not children. Section 25 sets out the procedures to be followed for the involuntary admission of children. These issues can be addressed prior to Committee Stage taking place.

In concluding my remarks this evening I ask Senators to bear the following in mind. We want children to receive treatment in age-appropriate units but we do not want to legally restrict the right of the medical profession in this regard. We all know that due to staff shortages, the Linn Dara facility was recently left with just half of its 22-bed complement operational. The core issue facing the Linn Dara facility, as we know, relates specifically to difficulties with recruitment and retention of mental health professionals. This, unfortunately, reflects wider health system issues. The problem in this case does not relate to funding availability and the HSE is intensifying its efforts on recruitment. In circumstances where staffing difficulties across the health services is an ongoing challenge, there are concerns that restricting the admission of children to adult units in exceptional circumstances on a formal statutory basis will reduce the services' capacity to meet the real inpatient needs of our children. That is why I wish to further discuss the details of this Bill with a view to incorporating the views of the expert group review of the Mental Health Act 2001. On the basis of these further discussions to take place, the Government will not oppose Senator Freeman's Bill.

That is the Department's view on the issues involved. It is its right, role and responsibility to do that. As Minister of State, I very much welcome the spirit of the Bill Senator Freeman has introduced. She and her colleagues have done considerable background work on it. I am very enthusiastic about working with her. We will take on board the Department's concerns. That is my role and responsibility. Through reasonable dialogue and compromise we can come up with a successful Bill from which future generations can benefit.