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

I thank Senators and welcome the motion as the promotion of positive mental health is a common objective within the Oireachtas and throughout Irish society.

The issues raised by the Senator provide the opportunity for us to consider the various and ongoing initiatives aimed at enhancing our mental health legislation, policy and services. These issues are being addressed in the context of progressing the commitments and priorities for mental health under A Programme for a Partnership Government. We are, for example, modernising the Mental Health Act 2001, refreshing A Vision for Change and we have been improving the existing capacity of our mental health service while introducing new initiatives.

My core objective, as Minister of State, is to improve how we plan services with an emphasis on delivering assessed and appropriate services to all of our population, especially those most needing care. We face increasing demands, evolving needs and heightened expectations. We also face limits in staffing resources. To meet these challenges, we need to look at new approaches and imaginative solutions.

I appreciate that the Senator has raised comparison of mental health funding as a proportion of overall health expenditure with 1980s figures. This, I suggest, should be considered in the context of changes to the health system as a whole. This includes, for example, various new service elements introduced across our health system in such areas as disability or services for older people. Such services simply did not exist in the past. In addition, the mental health system has totally transformed from primarily institutional-based care to largely community care, allied of course to modern inpatient care units that emphasise short-stay and recovery.

Significant mental health promotion and expenditure is undertaken in other areas for both children and adults, such as in HSE primary care or across other sectors such as education, Tusla or the judicial systems.Expenditure comparisons with other countries should also allow for the fact that they can have significantly different healthcare, social care or funding systems. Notwithstanding this, I reiterate that developing mental health services remains a priority for me as Minister of State and for the Government. This is being realised in practical terms by the additional €55 million to progress new developments this year, which brings overall mental health funding to nearly €1 billion. The HSE mental health budget has increased by more than €275 million since 2012, a significant investment by any measure or viewpoint.

In recent years, our services have broadened. They now range from mental health promotion and early intervention through to specialist acute forensic care. They extend also, for both adults and children, beyond the traditional HSE mental health programme to other areas or sectors. This involves, for example, better links to primary care, disability services and health and well-being. Increasingly, an improved response is also occurring across other sectors spanning education, childcare or the justice systems.

In recent years, the mental health system has received, rightly, considerable scrutiny from politicians, the media, advocate organisations, service users and many others. I welcome this scrutiny because it helps us to identify any areas in which performance can be improved. In this regard, I acknowledge the contribution of the Oireachtas. While mental health is a complex area relevant to us all, often involving profound issues and implications, steady and real progress has been made collectively over recent years. From my extensive interaction with many Members on many fronts, I am confident that this positive direction will continue, as it must do if we are to realise the further improvements we all wish to see. On this note, I held a presentation late last year in Leinster House to inform Members of the Oireachtas about our mental health service overall, and I arranged another one about a month ago specifically on child and adolescent mental health services, CAMHS. Many of the issues being aired today were covered in detail on these unique opportunities by officials of both the Department of Health and the HSE.

I will now update Members on some of the strategic developments on mental health and then address the more specific issues raised. The Department of Health is drafting a general scheme of a Bill to amend mental health legislation to reflect the recommendations of the expert group review of the Mental Health Act 2001. It is anticipated that draft heads of a Bill will be completed by the end of June next. The draft legislation at that stage will then be referred to the Mental Health Commission for its consideration. Mental health legislation must always seek to strike a fine balance between the rights of the person and the requirement to protect others. The comprehensive updating of the Mental Health Act 2001, along with the recently enacted Mental Health (Amendment) Act 2018, will ensure that in future a greater emphasis will be placed on the autonomy of the individual rather than relying on the principle of "best interests", as set out in the 2001 Act. It is accepted that people should have the right to make their own choices and that, where necessary, supports should be available to ensure a person's "will and preferences" are fully respected. The updated Act will put the focus firmly on protecting and promoting the human rights of those with mental health difficulties, thus ensuring their voice will be more clearly heard.

When launched in 2006, A Vision for Change was universally welcomed as a progressive, evidence-based and realistic document that proposed a new model of service delivery that would be patient-centred, flexible and community-based. The Government accepted A Vision for Change as the basis for developing our mental health services, and significant success can be noted in how the delivery of mental health services has changed in the intervening years. One important principle within this document reads: "Mental health services must be accessible to all who require them; this means not just geographically accessible but ... provided at a time and in a manner that means individuals can readily access the service they require." This relates more than ever before to the issues at hand today. It is generally accepted that A Vision for Change has been highly regarded, both nationally and internationally, for its underlying principles and objectives. The refresh of this policy, which will conclude shortly, will reinforce and improve these fundamentals while taking account of emerging needs and changing best practice for future years. We should recall where we have come from in that bed numbers have been reduced and old institutions closed. The new focus on mental health and deinstitutionalisation, which will be further supplemented and informed by updating A Vision for Change, looks beyond traditional psychiatric provision to include a more holistic approach and an agenda for social inclusion.

Of relevance also today is our suicide policy in that the Connecting for Life cross-sectoral steering group has an agreed national implementation plan. This was published in January 2018. In addition, all 17 local Connecting for Life plans have been launched and are being progressed satisfactorily throughout the country.

Improving access to the range of HSE specialist mental health services, whether they relate to CAMHS, general adult services or those for psychiatry of later life, is a priority under the recently agreed HSE service plan 2019. The plan highlights delivering timely, clinically effective and standardised mental health services in adherence with statutory requirements. It is important to note that mental health services are available to the entire population. Specialist consultant-led mental health teams are configured for this purpose and every person is eligible to avail of services. This includes asylum seekers and those in direct provision. These services are accessed mainly through primary care referrals, although referrals to community mental health teams can be made by any doctor who considers a psychiatric review necessary. This again is usually through primary care but these can sometimes come through emergency departments or other sources. The location of direct provision centres does not specifically feature in HSE resource allocation models or the available resources in specific catchment areas. However, each HSE community healthcare organisation allocates resources to provide the best possible level of service based on the needs of all the population served, including asylum seekers and those in direct provision.

Mental health services are mainly provided by community mental health teams. A HSE review of out-of-hours services in 2017 revealed that 60% of these teams were already providing seven-day-a-week services. Additional funding provided by Government in 2017 was allocated to increase this coverage to 100%. HSE mental health services are in the final stages of completion of this project, which will allow for the provision of 7-day-a-week services nationally.

As reflected in its service plan, the HSE is developing its prevention and early intervention services at primary care level. This includes a 24-7 mental health contact line, a crisis text line and a range of online e-mental health digital responses. The first of the electronic GP referrals to mental health services went live very recently. I will look at the potential of such initiatives in the context of the specific issues under discussion here today.

CAMHS is understandably an issue that is of interest to us all. It is designed for children and adolescents presenting with moderate to severe mental health disorders, as opposed to other HSE supports at different levels of care provision. The number of referrals accepted to CAMHS has increased by 24% between 2012 and 2018. Despite this increase, the CAMHS waiting list has increased by only 4%, or just over 100 cases, since 2012. The HSE service plan 2019 commits to developing all aspects of CAMHS services. This includes developing a seven day a week service to ensure improved supports for vulnerable young people as well as related initiatives around enhanced early intervention and day hospital care. When a referral is accepted, CAMHS teams are expected to offer an appointment and see an individual within 12 weeks. All community teams screen referrals received and those deemed urgent are seen as a priority. This can sometimes impact on seeing other cases within three months depending on local resources and circumstances. There has been an overall 8.2% increase in the number of referrals accepted between April 2018 and April 2019. In that time, the CAMHS waiting list decreased by 3.9%. At the end of April 2019, there were 2,606 cases waiting to be seen. This is an increase of 105 cases on the same period in 2018. The number of cases waiting more than 12 months decreased by 36, or 10%, to 316 in April 2019 compared with the same period last year. The HSE has established a CAMHS waiting list initiative to reduce waiting lists with a focus on those waiting more than 12 months. The community healthcare organisations with individuals waiting more than 12 months are taking dedicated actions to ensure no child is waiting beyond this period. However, this can be influenced by various factors such as an increase in population, increase in referrals, staffing retention issues and challenges in recruiting. CAMHS inpatient units operate a 24-7 tertiary model of care to young people with severe or complex mental health issues. There are 74 CAMHS inpatient beds in four units in Dublin, Cork and Galway. This number will increase to 104 with the opening of the new forensic complex in Portrane next year and the new children's hospital in the longer term.

Medical workforce planning within the HSE is the responsibility of the national doctors training and planning group, which considers the needs of service delivery across the healthcare system. It aims to bring the number of doctors in postgraduate medical training programmes in line with future demand for specialists in the health service and to help inform the consultant appointments process. The HSE maintains a doctors integrated management system that collates the registration, training and employment details of all consultant posts and whole-time equivalents on a single national system. The recording of all consultant posts allows for greater reporting at local and national levels and otherwise informs workforce planning decisions. A total of 452 consultant psychiatrist posts are documented on this system, with 418 consultant psychiatrists in post. The national task force on medical staffing was a Government policy document in 2003 that recommended that a ratio of 15 consultants per 100,000 of the population be achieved by 2013. This was followed by A Vision for Change, which recommended a target of 9.4 consultants per 100,000 of the population. In England, the current ratio of consultants to the population is similar to Ireland at 9.8. Workforce planning is under consideration in the refresh of A Vision for Change. I understand that around 12% of all consultant psychiatrist posts are either vacant or unmatched. Therefore, around 88% of all consultant psychiatrist posts are currently filled.

Regarding the question of bed ratios, I again stress that international comparisons often fail to take account of variations within countries in terms of mental health policy. Our health policies, Sláintecare and A Vision for Change, emphasise the importance of modern, high-quality care in the community with, of course, equivalent provision in hospital settings as appropriate. In Ireland, there are 1,035 acute beds for a population of 4.761 million. This means we have 65 acute adult beds per 300,000, or 21.6 per 100,000. This is in a context where A Vision for Change recommends a total of 16.6 beds per 100,000 population. Therefore, we have more than the recommended number of beds.I acknowledge, however, that continued investment in community services will be necessary to deliver fully on national policies.

Through its mental health engagement and recovery team, the HSE now has local fora for service users and their family members across the country. The HSE is ensuring that the views of service users, their family members and carers are central to the design and delivery of services. This is evidenced by service user participation on the HSE's management team. Improvements relating to embedding a recovery culture within teams and services are being supported through the implementation of the national framework for recovery in mental health. The talk therapy national service improvement project will further improve mental health services.

There is a whole-of-Government approach to direct provision in Ireland. The Reception and Integration Agency, RIA, provides material reception conditions - accommodation and related services - in line with the European Communities (Reception Conditions) Regulations 2018 to those in the international protection process. Other sectors are responsible for providing services directly through a mainstreamed approach. The Department of Education and Skills provides education services; the Department of Employment Affairs and Social Protection provides daily expense allowances and other exceptional needs payments. Some Departments and agencies have seconded staff to the RIA, and this system works extremely well in the provision of effective and efficient services to recipients. Mainstream health services, including mental health services for those in the international protection process, are provided directly through the HSE and the Department of Health. The HSE and other health providers arrange for translation services as required. The RIA works collectively with all agencies and Departments to co-ordinate the provision of services. There is ongoing liaison between the HSE and the RIA to best meet the health and related needs of protection applicants. There is a specific health screening team funded and managed by the HSE and located on the site of the Balseskin reception facility to assess recipients who have just arrived in the State. The team comprises GPs; a medical officer; a clinical nurse specialist and two nurses; a primary care social worker; two primary care psychologists; and clerical and administration support. The team offers a range of individual services and screening for medical and psychosocial needs, with onward referral as necessary. The individual professionals communicate with the RIA - within the bounds of patient confidentiality - if a need is identified that will affect the applicant's accommodation requirements.

The HSE social inclusion unit has commissioned research to explore the concept of vulnerability, good practice in assessment, timing of same and implications for effectively improving on the processes already in place. It is important to emphasise that all agencies involved in the delivery of direct provision services play a part in identifying and supporting applicants who present as vulnerable. This is particularly the case where vulnerabilities may become evident at different times in the protection process. Applicants can also obtain a General Medical Services, GMS, card on receiving a temporary resident card or a PPS number and can therefore visit a local GP or primary care service as required.

The next few years will see considerable change in the mental health landscape, with new legislation, improved infrastructure and refreshed policies in place. I assure the House of my personal commitment to a high-quality, person-centred mental health service, including for asylum seekers. Mental health problems, of whatever nature, do not differentiate. Everyone deserves the best possible response our care system can give. In this context I will give full and proper consideration to all contributions made today. I thank my officials, Mr. Gerry Steadman and Mr. Michael Murchan, who are here with me for their work on this issue and their presence today.