Seanad debates

Thursday, 9 February 2006

Mental Health Services: Statements.


12:00 pm

Tim O'Malley (Minister of State, Department of Health and Children; Limerick East, Progressive Democrats)
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I am delighted to be able to speak to Senators on the Government's policy document A Vision for Change, the report of the expert group on mental health policy. The report outlines an exciting vision of the future for mental health services in Ireland and sets out a framework for action to achieve that over the next seven to ten years. It is the first comprehensive review of mental health policy since Planning for the Future was published in 1984 and has been accepted by the Government as the basis for the future development of mental health policy.

I established the expert group on mental health policy in August 2003 in recognition of the need to review long-standing policy in this area and to formulate a blueprint for a modern, comprehensive, world-class service that can meet the mental health challenges that now face our society. Not least of those is our significant suicide rate, particularly among young people.

From the outset I was convinced that a collaborative approach between service users, professionals and health service providers represented the best way forward. Accordingly, I appointed an expert group chaired by the president of the National College of Ireland, Professor Joyce O'Connor, and which consisted of 18 widely-experienced people drawn from a range of backgrounds within the mental health services.

A Vision for Change builds on the approaches to mental health service provision proposed in previous policy documents and outlines a set of values and principles that will guide both the Government and service providers as we proceed to develop and put in place a modern, high-quality mental health service for our citizens.

The group undertook a wide-ranging and comprehensive public consultation process whose findings, which were published in two reports in December 2004, are central to the framework outlined in A Vision for Change. The consultation not only showed the wide-ranging knowledge and expertise of mental health issues that professionals and service providers possess but allowed service users to make clear their views on the present state of mental health services and on how such services should be developed in the future. The expert group felt it important to ensure that service providers articulated their priorities concerning the need for adequate resources to enable them to respond to the full medical, psychological and social needs of service users and their families.

Throughout the consultation process calls were made for significant change at all levels of service provision and in particular for the delivery of community-based interventions that are accessible, user-friendly and effective in promoting recovery and reintegration into society. The necessity of involving service users and their carers in all aspects of service delivery was a key message. This is the foundation on which A Vision for Change was built.

Another theme that permeated the consultation process and informed the development of every part of the policy was the need for greater access to psychological therapies, which are commonly known as "talk therapies". The demand for psychological and social therapies and the evidence for their effectiveness has been growing steadily in recent years. The clear consensus among users and service providers was that such therapies should be regarded as a fundamental component of basic mental health services rather than additional options that are not consistently available.

Although alternatives to medication is consistently a topic in any consideration of the future direction of mental health services, the expert group places strong emphasis on the need for much greater availability of mental health professionals within the community, especially mental health nurses, psychologists, counsellors, occupational therapists and social workers. It is vital that future service provision is person-centred and takes account of the resources and wisdom that already exist within the community. In recognition of this, the expert group proposes a holistic view of mental illness and recommends an integrated multidisciplinary approach to addressing the biological, psychological and social factors that contribute to mental health problems. The group recommends a person-centred treatment approach that addresses each of these elements through an integrated care plan which, reflecting best practice, is evolved with and agreed by service users and their carers.

As we are all aware, primary care provides most people's first point of contact with the health and personal social services. Primary care is the appropriate setting for meeting 90% to 95% of all health and personal social services needs, including mental health needs. All but the most complex and acute health care needs of individuals, families and groups can be effectively met in the local primary care setting. The provision of a wide range of care close to service users represents the most appropriate, effective and user-friendly approach to health care delivery. The development of primary care services as recommended in the report will contribute significantly to enhanced levels of care and treatment for those who suffer from mental difficulties.

One of the fundamental principles of this report is what is termed "recovery", in the sense that people with mental illness can and should be facilitated in reclaiming their lives and becoming involved in society, that is, to be what is termed "socially included". To achieve this people need supportive mental health services but they also need supportive communities where actions are taken to address basic needs such as housing, employment and education. All of these elements are included in the vision for the future outlined in this report.

A modern health care system accepts that each person must play a central role in their own treatment and recovery. It recognises that each individual plays a critical and essential role in the assessment of their own needs and that quality of care is inextricably linked to the involvement of the user in determining their health care. The goal of mental health promotion must always be the enhancement of potential, that is, building psychological strengths and resilience rather than focusing on reducing disorders. I believe it is a key task of the health services not just to treat mental illness but, more importantly, using the principles of health promotion, to improve the mental health and well being of all our people, both as individuals and members of communities within the population. I am pleased to note this report reiterates that ideal.

Thankfully, there is a growing awareness among service providers that establishing a good quality of life for service users requires their involvement in the planning of the services that are important to them and which support their choices. The perspective of the service user and their family or carers needs to be understood and appreciated. The vision that guides this policy requires that mental health services be characterised and led by a partnership between all stakeholders. A comprehensive mental health care system requires that services at all levels — from community support groups, to voluntary groups, to primary care, to specialist mental health services — work in an integrated, co-ordinated fashion for the benefit of all people with mental health difficulties.

This policy envisions an active, flexible and community based mental health service where the need for hospital admission will be greatly reduced. In this report, the expert group has stated:

Mental hospitals have been the mainstay of mental health services in Ireland for many years. However, the type of person-centred, recovery-oriented care recommended ... cannot be provided in institutions of this size or environment.

On that basis, it is recommended that steps be taken to bring about the closure of all remaining psychiatric hospitals which are a legacy of a bygone age and to re-invest the resources released by these closures in the mental health services.

Since coming to office, I have taken the opportunity of visiting a number of mental health facilities and have seen at first hand the commitment of staff to the provision of a high-quality service. From the outset, I accepted that further investment was required to upgrade or replace some of the physical facilities and that greater capital investment was required to provide a modern comprehensive community-based infrastructure.

The closure of large mental hospitals and the move to modern units attached to general hospitals, together with the expansion of community services, has been Government policy since the publication of Planning for the Future in 1984. A great deal of progress has been achieved since then, with the number of acute psychiatric units in general hospitals increasing from eight in 1984 to 24 at present. As a result of these developments, more than 50% of all admissions to the mental health services are now made to general hospital psychiatric units. Supported residential places in the community have also expanded, rising from 1,180 in 1984 to 3,508 in 2004.

A number of the large mental hospitals around the country have already closed completely — Our Lady's in Cork, St. Patrick's in Castlerea, St. Columba's in Sligo, St. Mary's in Castlebar and Our Lady's in Ennis. The reorganisation of services which these closures entailed resulted in the expansion of community facilities, new acute psychiatric units in some cases and an overall improvement for service users, their families and carers. The remaining hospitals cater in the main for long-stay patients, many of whom are over 65 years of age. This report recommends that a plan be drawn up for the phased closure of each of these hospitals.

It is recommended that this plan consist of a four stage process, as follows: stage 1 — identify measures required to enable admissions to cease and put these measures in place; stage 2 — cease admissions to the hospital and draw up plans for relocation of existing patients; stage 3 — implement plans for the relocation of existing patients; and stage 4 — final closure of hospital. It is emphasised that this process should take place on a phased basis with wards closing sequentially. It also makes clear that the process will require funding for training and upskilling of staff who will subsequently be redeployed to work within the mental health services provided in the community. This major change process will be undertaken and completed in full consultation with patients, their families and carers and, of course, the staff involved.

The expert group has indicated in this report that community mental health teams should be the cornerstone of mental health service delivery. It has recommended that well trained, fully staffed, community based, multidisciplinary teams be put in place in all services, providing mental health care across the individual's lifespan, from childhood to old age. To provide an effective community based mental health service, these teams should provide multidisciplinary home-based and assertive outreach care. A comprehensive range of medical, psychological and social therapies relevant to the needs of the individual service user and their families and carers should also be available.

The new national policy framework, A Vision for Change, makes clear recommendations on how the mental health services should be managed and organised in the future. These recommendations include the establishment of a national mental health service directorate within the HSE. It is envisaged that this directorate will play a key role in facilitating the implementation of this policy and thereby developing a modern mental health service that will benefit the entire population.

Another important recommendation in this area relates to the reorganisation of the current mental health catchment areas. It is proposed that each catchment area will serve approximately 300,000 people and the community mental health teams will be developed on that basis. Each catchment will be managed by a mental health catchment management team which would include key professionals, a service user and the managers of the relevant local health offices.

The report recommends that a programme of capital and non-capital investment in mental health services adjusted in line with inflation should be implemented in a phased way over the next seven to ten years, in parallel with the proposed reorganisation of mental health services. The proposed new workforce will comprise more than 11,000 staff throughout the service. Allowing for the assimilation of all existing posts, the expert group has estimated that a total of 1,803 new posts across the services, together with a total non-capital investment of €151 million per annum in addition to existing funding, are required.

Due to the current non-availability of certain health professionals, this investment will be required on an incremental basis, resulting in a proposed non-capital investment of an additional €21.6 million each year for the next seven years. Substantial additional funding will be required to finance the implementation of the recommendations outlined in this report. In this regard, I am pleased to confirm that in the Estimates for 2006, an additional €25 million has been allocated to the HSE for mental health services and it is hoped to continue this level of investment in the coming years.

It is important to point out that the expert group has recommended that this policy be implemented on a phased basis over the next seven to ten years. The proposed changes, therefore, will be incremental. In my opinion this is vital, not least due to the level of additional resources required but also the need for the changes to take place in a planned and co-ordinated manner in consultation with all those involved.

To date, mental health services, both statutory and voluntary, have met the challenges of change in recent years with enthusiasm and vigour and I am confident that the further development of our services, in a spirit of partnership between statutory and voluntary bodies, will be approached in the same positive manner. The Government is fully committed to the implementation of this report, which, as I said at the outset, has been accepted as the basis for the future development of mental health services. I will shortly appoint a group, as recommended in the report, to monitor the implementation of its recommendations.

I am confident the implementation of the recommendations contained in this report, in conjunction with the ongoing implementation of the national strategy for action on suicide prevention, Reach Out, will result in far greater provision of accessible, sensitive, appropriate and, where required, intensive support for all who need it. It will also ensure that mental health services will have the necessary resources to enable them to do that in a more comprehensive, co-ordinated and cohesive manner.

I again acknowledge the work of the expert group chairperson, Professor Joyce O'Connor, and of all the members of the group over the past two years. I look forward to working with those who will be involved in the implementation of this important report and the work therein.

Fergal Browne (Fine Gael)
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I welcome the Minister of State and his officials to the House. We on the Opposition side of the House welcome the report. The key aspect, as the Minister of State referred to in the latter part of his speech, is the report's implementation. It is good to make up a report over two years, but it is worthless unless it is implemented. Unfortunately, the Department of Health and Children has many reports on bookshelves gathering dust, with little else happening.

I am encouraged to see the last of the key recommendations in the report states "A Vision for Change should be accepted and implemented as a complete plan". That may be stating the obvious but it does not often happen. I welcome the aspect of the Minister of State's speech regarding the appointment of a group, as recommended in the report, to monitor the implementation of its recommendations. I hope such a group will set targets and benchmarks.

The difficulty with a ten-year plan is that it is such a long term. In real terms, that period will take in three Governments, or even more if a Government does not last five years and, were to be a Cabinet reshuffle every two and a half years it would be possible to have six different Ministers in that period. It is important that targets are set and benchmarked, and that progress is monitored. I appreciate that targets may not be achieved on occasion, but they may be achieved early in other areas. It would nevertheless be a way of ascertaining the effectiveness of the plan's implementation. I welcome those aspects.

There is much work to be done in the mental health area. I have recently been sitting, along with Senator Glynn and others, on an Oireachtas sub-committee investigating the high levels of suicide in Irish society. A valid point was made that if a person had a problem with an eye, he or she would have no qualms about contacting an optician or visiting a doctor to find help. However, if a person has a problem an inch above his or her eye, that is, mental health problems, action is not usually taken. This is true for men more than women. There is a problem in people not owning up to having a difficulty and seeking help. We should do everything in our power to remove the stigma of mental health problems.

I visited Scotland yesterday to see examples of how mental health problems are dealt with in that country. It is estimated that one in four of Scotland's population suffers some form of mental illness. This is startling. I am not sure of the figures for Ireland, but even if it is one in four or one in ten of the population, it is a high percentage.

Facilities must be put in place to address this. There is an institution in Carlow, St. Dympna's Hospital, but I am aware that the days of locking up hundreds of people for their entire lives in an institution are over. Thank God this is so. In reality, perhaps 1% or 2% of people would have severe mental illnesses that would require staying in an institution. Most people can receive treatment from time to time and recover.

Thankfully we have moved on from those days. I welcome the aspects of the report where it considers closing down the hospitals in some cases. I would be cautious about this, as we still need mental health institutions for a certain percentage of the population suffering from schizophrenia, for example, and other severe conditions. I would not recommend the closure of every mental health hospital in the country, as we should keep some open for the safety of patients and that of the public.

One can imagine the headlines if a person was released from a mental institution before committing a crime. Newspapers would be very glad to publish a major story. It could set the campaign to promote mental health back years if such a case occurred. Recently in England, a newspaper went to town on a person after a crime and the story made the front page. The same paper carried advertisements about seeking advice for mental health issues. After a campaign, the editor of the newspaper apologised and appreciated that he should not have done what he did.

There is a great facility in Carlow, and I am sure the Minister of State has visited the Delta Centre, which has done much work for people with special needs. It has an excellent multisensory garden, and there are now discussions about building a new autism unit for adults in Myshall with Ionad Folláin, which has a checkered history for a different reason. I hope this will come about and there will be a centre similar to a facility in Enfield in County Meath catering for adults with autism. Those people heading the Myshall project will shortly be approaching the Minister of State's Department with proposals. There are now many people with special needs living in special purpose houses in the community, and there is one beside my home. This is how it should be, as the days of being locked up in an institution are long gone, thankfully.

Those who were Members in 1984, before I was, have made the point that the report published then, Planning for the Future, contained many recommendations which are also contained in this report. We do not want the people in this House in 20 years' time stating that little progress has been made. Unfortunately we have seen very little progress from the 1984 report. Many of the recommendations in that report were not implemented.

It is interesting to note the level of funding. In 1984, the level of funding for mental health as a percentage of total health expenditure was 13%. By 2004 this had decreased to 7.34%. I appreciate that most of the finances in 1984 were spent on running major institutions such as St. Dympna's Hospital and others around the country. However, funding has not kept apace in the mental health area. In Scotland, 15% of the total health budget is spent in the mental health area. We have a long way to go and we should increase the funding, not necessarily for institutions but on other areas such as multidisciplinary teams, etc.

There is a major problem with young adolescents in the mental health area. There are only approximately 20 beds for this age group, in Galway and Dublin. The recommendation calls for 150 beds. This causes major problems also. A sum of €1.2 million was allocated towards the prevention of suicide this year, and Mr. Geoff Day will head up a new body. Some people would feel this amount is quite small. The stark facts are that approximately 500 people committed suicide last year, compared with approximately 400 killed on the roads. Yet the money being put into road safety is three or four times that being put into suicide prevention.

There is a startling statistic that over 10,000 people presented at accident and emergency facilities last year with evidence of self-harm. There is an estimate that the actual numbers of those who self-harm could be as high as 60,000. Some people engage in self-harm but do not require medical attention. That is also a major issue, and we must substantially increase the funding available for the prevention and treatment of parasuicide and suicide. This is especially true for the families involved, who can be left in chaos and badly affected following a suicide.

I would be cautious about using the sale of hospitals to fund new developments. This does not happen in any other area. I appreciate that money raised from the sale of a hospital should be ring-fenced for mental health projects, but such projects should not be dependent on such funding. In other areas projects have received money without a clause being involved about sale of relevant property.

The Minister of State mentioned new staff, particularly increasing numbers by 1,800. Will they be available immediately or is it over the long term? I am conscious the Minister of State has stated this will be done over a ten-year period. Would the staff be available if the process was fast-tracked over a period of two or three years? I understand such a supply of staff is not available in Ireland. I urge the Minister of State's Department to discuss this with the Minister for Education and Science, Deputy Hanafin, to ensure the number of places on certain courses are increased substantially to allow for staff increases. We should ensure we avoid the scenario, in a few years' time, where we have the money to increase the number of places, we have the facilities but we do not have the staff.

I appreciate that an extra €25 million has been provided for mental health this year but that is less than half the cost of e-voting, which was €60 million. The PPARS system cost €150 million and the Dublin Port tunnel has gone over budget by €400 million. The public is fed up with such overspends when a tiny fraction of that money could be given to worthwhile projects like mental health. The Minister of State should fight tooth and nail to increase that figure substantially in future budgets. If we can manage our money better we should see more for worthwhile projects.

I collaborated on a parliamentary question tabled by Deputy Keogh on 25 October 2005 arising from a meeting we had with a group about psychological services for young people. The question asked if the different waiting times for persons waiting for psychotherapy, counselling or associated services throughout the country would be published, and if the Tánaiste and Minister for Health and Children would differentiate between those awaiting adolescent and child services. The question was asked because we have all heard anecdotal evidence of long waiting lists, though we cannot prove it. I only received the answer from the HSE today, almost 100 days later, by e-mail. It illustrates the frustrations involved in finding out the answer to such questions. It reads:

Psychotherapy and counselling, in broad terms, describe a range of therapy interventions, sometimes described as "talking therapy". The HSE directly provides a number of services including adult and child psychiatry and national counselling services are also accessible. Counselling is also available in the context of our drug and alcohol services. The HSE provides funding and support to a number of agencies that provide counselling services, for example rape crisis centres and bereavement support groups. Counselling is also offered as an integral part of many treatments, for example pastoral care and palliative care in a hospice setting. Counselling services are also made available for those facing traumatic life-altering experiences in the context of oncology services and genetic counselling.

Many of these services are offered on a person-centred basis and no waiting lists are maintained. Mental health services (adult and child adolescent services) are available on a time-waiting basis but urgent and immediate services are available.

After 100 days I am certainly no wiser. All I can gather is we do not have formal waiting lists. I will give a copy of the e-mail to the Minister of State and I ask him to look into it because it is not a satisfactory reply. I now believe the people who have come to me and said they have been waiting many months for services because we cannot prove they are not waiting months or even years. The answer is inadequate for a Member of the Oireachtas who asked it following a submission by a group before an Oireachtas sub-committee.

I will briefly go through the recommendations in the report. The second recommendation is that mental health promotion should be available for all age groups, which I welcome. I will highlight young people in particular, whom we are failing at the moment. Adolescents should be a priority in the implementation of this recommendation.

I welcome the use of the phrase "multidisciplinary approach" because we should not leave mental health to psychiatrists, though Senator Lydon might not agree with that. Many people are involved in this area and we should ensure we get the right balance, though it is difficult. I appreciate the role played by occupational therapists, clinicians and others.

The report recommends that the link between specialist mental health services and voluntary groups supportive of mental health should be enhanced and formalised. That point came across loud and clear to me during our hearings on mental health. I was amazed at the number of groups that exist but it struck me that there was a lack of co-ordination and some replication, and that there were pockets of the country where there is no service. We should make a recommendation for greater co-ordination, to ensure we have a proper regional balance and to strengthen areas where we are weak.

Another section recommends that the organisation and management of local catchment mental health services should be co-ordinated locally. Does that go against the idea that the HSE is the one body for the whole country? Having abolished health boards and created the HSE are we now going back on that in the area of mental health?

I urge caution on the proposal for the closure of mental health hospitals because we still need proper facilities for the 1% to 2% of the population who have severe mental problems and who will probably need to stay in a mental hospital for most of their lives. Another section of the report suggests that mental health information systems should be developed locally. I again urge caution because PPARS springs to mind. I appreciate the difficulties in combining health services and information technology but I hope we have learnt from PPARS.

I am also concerned about the right to privacy of patients. If a central IT system is put in place how can we ensure patients have privacy? Names might be withheld or numbers allocated but I foresee difficulties in that area. A lady recently phoned me to complain about a neighbour who had been doing work for her through her husband, of which she had been unaware. Even though she had tried to commit suicide she found it difficult to sign herself into hospital. The hospital had to sign her in against her wishes. She was not aware that her husband had organised for her to be signed in for her own safety.

In Scotland a special group has been set up to secure work for people with mental illnesses, through job clubs, etc. Scotland has a similar population to ourselves and has a great success rate in reintegrating people into society. We should consider such an initiative here.

I welcome the report and hope that far more of it is implemented than of the last report 20 years ago. I have tried to be constructive and hope the Minister of State will take my points on board when he makes his reply.

Don Lydon (Fianna Fail)
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I welcome the Minister of State and the report. When we get a report in this country it is assumed to be gospel. Even though it is prepared by a group of experts it does not mean it constitutes the only approach. Most of the report is very good and I have no complaints about it. A Vision for Change is a comprehensive model of mental health service provision for Ireland. It is a very wide-ranging and ambitious report and the expert group has done a very good job. I will go through its points in the order in which they appear in the report.

The report emphasises the need for multidisciplinary teams to operate in a truly integrated way and offer a wide range of treatment options to service users, which is extremely important. When I began working in a psychiatric hospital 30 years ago that was not the norm but it is now, importantly so. Each person in the team has something to contribute that the others do not.

The Minister of State mentioned the demand for psychological and social therapies, which is a very important feature of the report. It does not dismiss the need for medical treatment such as psychotropic drugs or treatments for depression, manic depressive psychosis, schizophrenia, etc., but it does emphasise that therapy is necessary.

The report also stresses the need for services to become community-based. We in the hospital have always had a problem when people were ready to be discharged in that there was nowhere to discharge them to. They could be sent back to their GP but there were no supports in the community, so I welcome the emphasis on that in the report. We were always the Cinderella of the health services. However, under the Tánaiste, who is fearlessly dedicated to improving the health services, and the Minister of State, funding will be put in place over time.

Integration into mainstream community life is of great importance. People with psychiatric illnesses cannot simply be discharged into the community without support. Social workers must work with families and constant therapy is needed over the long term. The development of these supports would be welcome.

The majority of people do not realise the serious impact of mental health problems. The WHO has calculated the global burden of disease and found that mental disorders rank second after infectious diseases. Mental disorders extract a greater toll on the health of the world's population than AIDS, TB and malaria, combined. Of the ten leading causes of disability worldwide, five are mental health conditions and the impact of mental health problems at a population level continues to grow. Apart from the physical costs to people in terms of health, it will become a significant economic burden if it is not addressed. However, it can be treated, although the report is welcome in its emphasis on primary care prevention rather than on cures.

The scale of the problem is enormous. For example, the total financial cost of mental ill-health in Northern Ireland has been estimated at £2.8 billion. What that phenomenal figure would amount to when multiplied across the entire island can only be imagined. In addition to helping people, anything that can reduce the cost to the Exchequer must be welcomed.

The report mentions social exclusion, which is an important issue because, while most people believe they do not know anybody who suffers from mental health problems, the issue is widespread throughout the community. People can develop mental health problems as quickly as physical ones but, while the stigma attached to psychiatric problems is gradually decreasing, fears of so-called mad or depressed people continue to exist. Most of these illnesses are transitory in nature, although some are long term, and sufferers can be helped.

Social exclusion, whether in terms of mental health or other areas, has to be tackled. The report suggests greater contact with individuals suffering from mental health problems, although demands for privacy are understandable. I have encountered people in good jobs who were passed over for promotion because of a short spell in a hospital or day care centre, even though they were capable of the responsibilities involved. This would not happen in the case of a recurring physical illness.

Priority issues in mental health include the following: promoting positive mental health and well-being; raising awareness of the importance of mental health; enhancing the capacity of mental health service providers and the wider community to promote mental health; and suicide prevention. Suicide is an ongoing problem in the country because it is difficult to prevent but nobody could disagree that we must establish its causes as best we can.

The report states:

Effective multidisciplinary working is dependent not just on having the requisite mental health professionals in place. It depends on mental health professionals changing how they practice and work together, so that they work as a team. An assumption that this will somehow happen if a variety of mental health professionals is appointed is somewhat naïve.

I have seen a wonderful multidisciplinary approach in England, where equal responsibility was assigned irrespective of profession. However, there is an occasional tendency on the part of some medical professionals to look down on social workers, occupational therapists, psychologists and other professions.

If the Minister of State is ever in Lisbon, he should visit the establishment there run by the order of St. John of God. The centre's patients, who have psychiatric illnesses, learning disabilities and other issues, are largely treated by occupational therapists. It is the only place in the world where such therapists practise the contents of their manuals and they shine in their work. We ignore these professions at our peril.

With regard to child and adolescent mental health, the report recommends 100 inpatient beds nationally for under-18s in five units of 20 beds each. I hope they will be composed of separate units for different age groups because there is a need for adolescent psychiatry. As some 12 year olds behave like 20 year olds and others like five year olds, there has to be a degree of leeway. Many years ago, I received a Council of Europe medical fellowship to study the residential treatment of disturbed adolescents, a service which is needed here. We also need two or three units for grossly disturbed adolescents where intensive work can be carried out over a long period of time.

I do not see any recommendations in the report in terms of ranks of psychologists and social workers, but that may not be important. All I will say is that they may need to be senior in rank.

Difficult to manage behaviours come in two types, namely, acute short lived disturbance, typically resulting from psychotic illnesses, and more enduring mental health problems. The former require close observation for a short period, while longer term care and rehabilitation in purpose-built accommodation is required in the latter case. I am most concerned about longer term problems because I have met a number of disturbed adolescents who have no place to go for care. There are beds in a unit in St. John of God's and some other places but they are not sufficient. The issue must be carefully investigated.

I laud the recommendation that any person aged 65 or over with primary mental health disorders or with secondary behaviour and affective problems has a right to be cared for by the mental health services. We need to learn the reasons for the increase in Alzheimer's disease and other illnesses.

The recommendation for a liaison mental health service is one of the most important elements of the report. Such a service will help hospital patients deal with a range of matters. Years ago, when I lectured nurses studying oncology in St. Luke's Hospital, somebody would go into hospital for something like a testicular biopsy or to have testicles or breasts removed — those features that made them essentially a man or a woman — with no counselling or preparation.

Some of the more horrific operations, particularly involving the genitals, were needed for lifesaving purposes but the patients were never tutored or counselled beforehand. This is an important area and I am glad to see that it is mentioned in the report.

On the area of neuropsychology, I note that such services will be sited at St. Vincent's, St. James's and the Mater hospitals. Why will there not be a unit located at Beaumont Hospital? Perhaps there is a good reason for this and I would welcome an explanation from the Minister of State.

People with borderline personality disorders are horrendously difficult to deal with because they need ongoing, and at times intensive, care.

Although this is an excellent document, it has one major flaw. Mr. Jung said that people could never be cured of mental illness or mental problems unless their souls were cured but I see no reference anywhere in the report to chaplaincy. The Minister of State mentioned the holistic approach, the bio-social model of care which has psychological, social and biological elements but there is also a spiritual side to this issue. I have witnessed, first-hand, cures effected by the intervention of chaplains in certain cases of mental illness which I can prove. Chaplaincy must be included and perhaps should form part of the proposed multidisciplinary teams. It certainly has a very important role to play in the area of mental health.

I agree with the Minister of State's intention to close the large mental hospitals but the smaller psychiatric hospitals still have an important role to play. I do not think they should be closed because in my own experience, patients are constantly referred to such hospitals from units attached to large general hospitals. The general hospitals could not deal with them and dumped them on the psychiatric services, and I use the word "dumped" advisedly. A properly-run, small psychiatric hospital of 150 beds or so can have a pleasant, peaceful ambience, considerable interdisciplinary interaction and provide patients with a feeling of privacy and safety. In general I welcome this report.

Mary Henry (Independent)
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I welcome the Minister of State to the House and I also welcome this very fine report. It is a privilege to speak after Senator Lydon and we are very fortunate in this House to have someone of his professional experience comment on the report.

In view of the fact that the chairperson of the expert group was Professor Joyce O'Connor, who is a friend of mine, I was not in the least surprised at the thoroughness of the report and the enormous amount of work that obviously went into its preparation. All those who were involved in the preparation of the report, some of whom are in the House today, should be complimented on its breadth and on the amount of effort that went into its publication.

I can remember the launch of Planning for the Future over 20 years ago and while a considerable amount of that report's recommendations have been fulfilled, a great deal have not. We all know the reason for that, namely, a lack of resources. Insufficient resources were put into moving psychiatric services out of the old mental hospitals and into the community or the wards in the acute, major hospitals. I regret this very much because we could be much further on in terms of development had the resources been invested over the years. Nonetheless, I welcome the Minister of State's commitment to the area of mental health.

I discovered recently that more money was paid out for long-term disability payments to those with mental illness than was spent on the entire mental health service, including capital spending. That is a shocking statistic and indicates how serious the burden of mental illness can be, not just on the individual and his or her family, but on the economy also. Like Senator Lydon, I was very taken with the various statistics from the World Health Organisation about the burden, internationally, of mental health problems.

There is still a stigma attached to admitting to mental health problems and that is why there is far less pressure put on the health services to deal with mentally ill people and to resource the services better. The amount of funding for mental health services, as a proportion of the total health budget, has dropped from 11% ten years ago to approximately 7% now. This demonstrates the fact that the general population is not putting pressure on the health authorities to improve the situation for those with mental illness. We hear about problems in accident and emergency departments all of the time, but we rarely hear about the fact that people with acute mental illnesses are unable to gain admission to hospital.

It is important that, while moving as much of the service into the community as possible, we remember that people with mental illness of all ages will require acute admission occasionally. It is for the Minister of State and those involved in the area to decide whether such admissions are to one of the present-day large psychiatric hospitals, where bed numbers are greatly reduced, or to a ward in one of the acute general hospitals. However, I am repeatedly asked by psychiatrists to emphasise the fact that acute beds are still needed in the mental health service.

One of the best aspects of this report is the fact that patients, their families and carers were widely consulted as to their needs, rather than the top-down approach of those providing the service, working in the Department of Health and Children and the HSE deciding what was best for them. The emphasis on patients deciding what is best for them is very welcome.

A considerable amount of discussion has centred on the relative merits of the various therapies given to patients with mental illnesses, for example, drug therapy and the so-called talk therapies. For approximately 40 years, drug therapy was extremely popular and made a very significant contribution to dealing with those who had serious mental illnesses such as psychoses, schizophrenia, bipolar disorder and so forth. Such people, whom I saw as a student in the major psychiatric hospitals here and in the United Kingdom, would have had no hope of being discharged and returning to the community without drug therapy. In that context, we must remember that drug therapy has made a very important contribution to the treatment of mental illness over the past three or four decades.

The Minister of State is correct when he says that today people are more interested in psychological services but frequently these are not available. It appears to me that there are large numbers of people training in psychotherapy, psychological assessment and so forth. Is it the case that the necessary posts are not being created? Is it that qualified people are available but the posts have not been created to enable them to treat those who would prefer to try talk therapies before becoming involved with drug therapy?

There is an excellent series running on RTE Radio 1 at the moment called "The Other Side of Childhood" about children with behavioural disorders and mental illnesses. Last night the programme dealt with attention deficit disorder. The presenter, Ms Mimi Tatlow, and a panel of experts discussed the drug Ritalin and attention deficit hyperactivity disorder. I come from that part of medicine which is very anxious about medicalising behavioural disorders but these are areas that must be examined. We must also ensure that we are paying enough attention to child and adolescent psychology. Senator Lydon pointed out the shortage of beds for serious cases but the psychological services for schools are also deficient. We must pick children up who have been put down as having behavioural disorders. It totally disrupts their educational career without doing anything for them.

Most of the research into mental illness is done with drug therapy because the pharmaceutical companies pay for it. Now we must pay up ourselves for the research into talk therapy. It will be worthwhile and resources should be invested in it. Senator Lydon was right to mention the lack of chaplaincy because that could also fall under talk therapy and is not to be underestimated. I could not find anything in the report about the genetics of mental illness. We must look at this area with care; it is sensitive, but we must not neglect it.

The Minister of State is right that it is difficult for patients to be allowed to recover from mental illness. I have written in the medical press that I am disgusted at the objections made to small houses in certain areas where three or four people with mental illness could go after they had been discharged from hospital. What sort of attitude is that? Communities must become more supportive. People can develop mental illness at any time of their lives. The fact people in a house on one side are recovering does not mean that the people on the other side will not develop mental illness in the near future so it is ridiculous not to support those who are doing their utmost to recover. Flexible employment is also important as is the maintenance of people in education. The universities have become much better about this when people have had to drop out for a while and then come back.

Team work is very important. Multidisciplinary teams are needed all the time but I had a bad experience in this area lately. A psychiatrist was appointed to work with the homeless in north Dublin but when she insisted on the appointment of a team to support her in her work, her post was cancelled. I do not know if anything has been done about it but there was talk about it in the psychiatric community and it does not encourage people when such things happen.

The day hospitals have not been successful because many of them are in the old psychiatric units and it would be better if they were associated with larger primary health care centres, such as the one in Ballymun.

I am glad the Health Service Executive and the psychiatrists have settled their differences about the mental health tribunals. I was involved in the legislation on the Mental Health Act and I felt that these tribunals were incredibly important. Approximately 3,000 people are still admitted involuntarily every year, a much higher incidence than in most European countries. We must examine this and get the tribunals going. I hope my psychiatric colleagues feel they can come forward now.

I approach legislation involving medical practitioners from the viewpoint of how those on the ground will work it. This is why I asked for retired psychiatrists and people who have worked in Northern Ireland to serve on the tribunals to encompass as many people as possible. Otherwise it will not be easy to get the personnel to do this.

I am concerned that not enough consideration has been given to the workings of the Criminal Law (Insanity) Bill. When the Minister for Justice, Equality and Law Reform was in the House, I tried to get him to bring it into line with the Mental Health Act. Frequently the same people will work both. Unfortunately he did not agree with me because, he said, different people are being dealt with. I am not sure he is right. Senator Lydon pointed out that many mentally ill people who are convicted of a crime are convicted of minor offences such as stealing a pint of milk from a supermarket, breaking a window or running up and down in the traffic and being a danger to themselves and to others. I would be grateful if the Minister of State could ascertain if the Minister might be more amenable to my views.

It is disappointing that local services will not accept people who may have a criminal convictions for minor crimes. The prison population has a far higher than average level of mental illness. The psychiatric care situation has improved but it is not yet good enough.

I was interested to hear the Minister of State say that it would be better if the Central Mental Hospital was not on a site associated with a prison but there is not much we can do about that, the main reason being the site in Dundrum is so valuable. It is unfortunate that this is the main reason for transferring a hospital into a prison setting. The Minister for Justice, Equality and Law Reform, on Committee Stage of the Criminal Law (Insanity) Bill, referred toHannibal Lecter but there are not too many such people around. I hate to see us making our plans based on the most extreme cases.

We are all living longer so old age psychiatry must expand, as must psychiatry for those with intellectual disabilities, who are also living longer. These are addressed in the report and are important issues.

The Minister of State should get hold of the Minister for Finance; he can decide if this will succeed or fail because huge resources are required. The will exists in the Department and the Health Service Executive but great plans have been brought forward in the past that have perished because of a lack of resources.

1:00 pm

John Minihan (Progressive Democrats)
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I welcome the Minister of State to the House. I appreciate having these few moments to speak on a topic that is as important to debate as it is complex and difficult. The information provided by the Minister of State and the Department on the prevalence and economic cost of mental illness is quite staggering and truly places today's statements in context. One in four people will have a mental health problem at some point in their lives with an estimated total annual cost of mental ill health of €11 billion to the country. Mental disorders rank second in the global burden of disease, second only to infectious diseases.

The Minister of State has personally championed this issue over many years and has been good enough to come to this House regularly to apprise us of developments. Members of this House are, therefore, better versed than most on these matters, and I thank the Minister of State for this. Nevertheless, it is worth setting out these figures again at the outset to provide the proper context.

It has become apparent through debates in this House, the media and elsewhere that Ireland needs a new mental health framework, some defined structure within which to create and promote positive mental health across its communities. The expert group on mental health policy appointed by the Minister of State, Deputy Tim O'Malley, was charged with preparing a new national policy framework for the mental health services, which would update the 1984 document, Planning for the Future. As the Minister of State noted, a framework within which accessible, community-based, specialist services for people with mental illness must also be provided. I am heartened that today's document, A Vision for Change, provides this much-needed framework, within which we can best promote mental health and best provide services.

I thank the chair of the expert group, Professor Joyce O'Connor, president of the National College of Ireland, and the group's 18 members for the excellent, considered, efficient and laudable work they undertook over a relatively short period.

It is worthwhile to briefly examine the seven main elements of the document. When debating child care much currency is given to what is known as a child-centred approach. This is as it should be and is exactly how current Government child care policy is framed. The same logic is extended in two ways to the area of mental health in the document, A Vision for Change. Users of mental health services must be involved at all levels of service delivery and be partners in their own care. Only then can we state that provision of mental health services is truly person centred.

Another key part of the report deals with care plans for users of mental health services. The report recommends that such plans mirror users' needs, goals and potential — a concept known as recovery-orientated care — in order to properly address those community factors which hamper recovery.

I am especially interested in the report's treatment of an holistic approach to mental health services. As legislators it can be difficult to make the clear link between what we have the power to do and what is needed in society. This is particularly true with regard to complex issues such as mental health. The holistic approach referred to in A Vision for Change sets out the importance not only of the biological element, that is, medication and treatment — to which Senator Henry alluded — or the psychological element, that is, the various therapies and techniques, but also the social element, namely, education, training, employment and housing. These are facets of society which we, in this House, deal with and influence in our work. Without arguing that an excuse existed in the past, A Vision for Change sets out the linkages entailed in a truly holistic approach to mental health. As members of the wider community, Senators must be cognisant of this fact.

Before leaving the topic of the balance between biological, psychological and social elements, I will make one important point. Fears have been expressed about an imbalance in biological and therapeutic treatment. As a pharmacist, does the Minister of State agree that pharmacies have an important role to play in the delivery of care and in the area of monitoring and that they must remain independent of prescribers if they are to fully fulfil their role in monitoring therapeutic treatment of mentally-ill patients?

Before I raise the importance of taking a multidisciplinary approach, it is important we do not overlook the fact that in 2004 more than 1,200 patients had been in hospital for more than five years. Community-based services are an integral part of the recommended way forward. The objective is to provide services, including treatment and outreach services, in the home and reduce hospital admissions.

We have so many excellent professionals working in this sphere. When I spoke yesterday in the House on developments in third level education, I referred to the importance of connectedness between experts and institutions to maximise the benefits of the excellence available in that sector. In mental health, too, the need for doctors, nurses, psychologists, social workers and occupational therapists to connect and coalesce as teams on a regional basis has been made clear. We must continue to move away from the "doctor knows best" approach. Multidisciplinary teams would have the benefit of self-governance and, importantly, the responsibility to be truly accountable to service users, their families and those who care for them, with a view to empowering all those involved.

A final key element in the report is its call for a full population-based focus. The experts make clear that consideration must be given to the entire population's mental health and wellbeing from childhood through to old age. There may be a tendency to categorise current and future service users into a small number of simplistic groups. This creates the wrong paradigm within which to promote mental health and provide mental health services. It is obvious that a wider and more nuanced focus must be employed.

The voluntary sector and those on the ground who work closely with the mental health sector have responded to A Vision for Change with a statement that the report could be Ireland's final chance to develop a balanced and integrated modern mental health service. It is described by Mental Health Ireland as "comprehensive and practical and, as such, warrants careful study not alone by Government but by all groups concerned with the welfare of people with mental illness".

While the voluntary sector has welcomed the document, it would be remiss of me not to note the sense of scepticism which accompanies its commendation of the report. We must meet that scepticism head on. If the sector fears the report will gather dust or will falter due to lack of funding, we must assure it we will not let that happen. The Minister of State has placed on record the determination of the Government. He has also invested much in trying to make progress in the area of mental health services. Throughout this debate, we must restate our commitment and continue to reassure.

The mental health policy proposed in this excellent report will require substantial funding. The considerable equity of buildings and lands within the current mental health system should, if necessary, be realised. The report recommends the closure of psychiatric hospitals and re-investment of resources into mental health services, as opposed to the sale of assets to benefit the State, the Exchequer, developers or speculators. The process must be managed in a way that maximises the direct benefit to service users. I am sure the Minister of State is mindful of this imperative and I encourage him and the Department to work to this end.

Following the publication of the White Paper on the re-organisation of the Defence Forces, the Government made a similar commitment when it undertook to streamline the Defence Forces and dispose of assets, namely, military barracks. The money realised from the sale of these assets was to be reinvested in the Defence Forces. This commitment has been met and we must ensure this commitment is maintained when assets are realised in the mental health sector.

I congratulate the Minister of State, the expert group, all those who were consulted and who made important contributions to the group's deliberations. I also congratulate the Tánaiste and Minister for Health and Children for raising the matter. A Vision for Change provides an important national policy framework for moving us to the point at which society gives everything in its power to promote positive mental health across communities and provide accessible, community-based specialist services.

Photo of Brendan RyanBrendan Ryan (Labour)
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Cuirim fáilte roimh an Aire Stáit. I welcome the Minister of State. The document is impressive and important. There is an adequate supply of copies and it is a pity one was not automatically sent to each Member of the Oireachtas when it was published. I had to seek my copy, which was provided expeditiously by the Department. Since I have a three-volume assessment of tax breaks that arrived automatically I do not know why an equally important document about our mental health services did not also arrive automatically. That is a comment for the future, not a criticism.

It is difficult not to inject a tone of scepticism, not cynicism; I am not a cynic. Nobody could survive 25 years in politics if he or she were entirely cynical. One would find something better to do with one's time. While there is a wonderful plan here — I have some reservations about some aspects of it — when there is a shortage of funds the mental health services are the first to be cut, and when funds are available they are the last to be funded. I have observed this and, when I have not, it has frequently been brought to my attention domestically. This is for the human reason that while a public patient who cannot access, say, a heart bypass operation is prepared to go on a public platform and complain, a person suffering from severe depression who cannot get a hospital bed is unlikely to be able or, more important, willing to so the same. Mental illness becomes invisible and is therefore the easiest area to neglect. That is an appalling comment on the management of our health services. It suggests that when the management of the health services needed to cut costs it did not use objective criteria of comparative priorities — I do not say that cutbacks are ever right — but looked for the easiest areas. A person paid to manage should not do what is easiest but what his or her managerial authority says are the right things to do. This was not done.

For a programme of change on this scale we first need the creation for me and others like me of the confidence that those who manage this will do so properly and on the basis of the objective priorities identified here, not on the priorities of the service providers such as psychiatrists, psychologists or occupational therapists. We also need the funding, which I think the Minister said would be provided. While he acknowledged and identified the €25 million extra that is to be provided in 2006 he did not quite say the Government is committed to providing the funding to do everything the report requires. I would like to hear from a Minister that we are committed to the full implementation of this and that the necessary resources will be provided.

Tim O'Malley (Minister of State, Department of Health and Children; Limerick East, Progressive Democrats)
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The Tánaiste gave that commitment at the launch.

Photo of Brendan RyanBrendan Ryan (Labour)
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I missed that at the launch and it is not quite clear in the Minister of State's own script. I am glad that is true because it is extremely important. I am here the day after I discovered a commitment not to impose a large debt on Cork Airport was not really a commitment but a hope. I accept the Minister's bona fides. Let me not get involved in silly nonsense. If the Minister says so, I accept that at this moment the intention is to fully fund it and I will move on.

I want to say something that may get me into trouble. It is important that early 21st century humanity gets it into its head that unhappiness is not an illness and that the remedy for every individual's sense of discontent with the world and his or her position in it is not a service provided by the State or, worse, some self-appointed guru. I am very taken with a recent definition of "guru". A "guru" is the name used for charlatans by journalists who cannot spell "charlatan". I am sceptical. This is not entirely my own view but is an issue about which many people in the area of caring for people with mental illness are concerned. For every new manifestation of human unhappiness the response is to provide some therapeutic service. All of us must live in a different world in which there are degrees of isolation and change due to family breakdown that did not exist before and, to a degree, we must be able to tell people that part of this is the process of maturing. Let us not expect the caring services to provide for everybody. The mental health services must focus on three areas — those who are demonstrably psychotically ill, those who are abnormally emotionally distressed, and those who, without support, are likely to fall into one of those two categories in the future.

I welcome the intent of the report. It is a fine idea that the users of services should be listened to. It is probably frustrating to have to read this over and over again. It the malaise of large organisations, not just public ones that many stakeholders perceive that others do not listen to them. For simplicity let us refer to stakeholders in mental health as those who provide and use services and see that as a large organisation. For example, there is no point in asking people who use services what they think of the service and what they think should be done about it if one does not give clear and explicit responses to their suggestions. One does not have to do what they suggest, but what drives people around the bend is feeling they were not responded to. It may not be possible to do some things, but 90% of people can deal with that if the reason is explained. They cannot deal with the apparent fact that their well thought out comments disappear into some miasma and are never responded to. That is important.

I am taken with the willingness of the report's authors to see mental health in terms of biological, psychological and social needs and the need for an integrated care plan. I am worried that the report unintentionally presumes a single model of society based on everybody having a family within which they can be cared for. One of the fundamental changes taking place in every Western country is individual isolation. We will catch up on this as we have with all the other problems of success. I am not nostalgic for the Ireland of the past. For most people it was a dreadful country and for many it was not even a country in which they could live. However, I believe there are problems of success, one of which is individual isolation. Some 42% of the adult population of the United Kingdom are now living alone. It is not possible to base a model of service on the presumption of a supportive family. To a degree, the recommendations of the report are most welcome. However, to coin a phrase from the report, it needs to integrate with the way society is as distinct from an idealised model.

For instance, one of the consequences of our prosperity is that voluntarism is declining, not because people are less generous, but because people who previously had no such opportunity now have access to a paid job, which automatically means that the number of hours in their lives available for other matters is reduced. Therefore, we cannot presume that NGOs and voluntary groups, which are cited in the report as being partners, will continue to exist in the form in which they used to, as they may no longer have the membership and support to do so.

Nobody would dispute the value of specialist multidisciplinary teams. In a team involving a psychiatrist, a psychotherapist, a psychologist, an occupational therapist and a nurse, it is extremely important that the caseload of each matches. It is not practicable to have a psychiatrist whose caseload would be, let us say, 20 patients per week while the psychologist can only handle five, because he or she needs more time. This would result in dreadful mismatches. We must work out the issue of the time involved in dealing with such cases. It cannot be just one individual. The whole structure of a multidisciplinary team providing services to individuals must be based on an agreed hours allocation and not just on people. While one body can formulate policy, resources need to be available to provide a service. Engineers would refer to a critical-path analysis being important. It makes no sense to have a succession of service providers with one in the middle who, through no fault of his or her own and through no negative intent, causes a backlog. It is important that managers in particular listen to this.

I am concerned about the role of primary care, particularly the role of GPs in a country that is short of them. My GP has not needed to deal with psychiatric illness on my part, whatever about anything else he has needed to deal with. It is unreasonable to believe that he would give the amount of time to which we would aspire.

While I am not being sarcastic, it is a pity that the executive summary of the report contains no reference to its recommendations on services for the homeless. It does not help one to believe that it was a real focus. The proposals for services for the homeless reflect an excessively optimistic belief that somebody else will provide housing for homeless people. If this happened, of course many issues would be solved. However, we cannot get away from the fact that we have a housing crisis.

It is not possible to deal with psychiatric services for homeless people in a community of which they are not part. To a degree the recommendations in pages 143 to 147 are posited on the assumption that adequate housing will be available for homeless people. I have no reason to believe this will be the case. While there is an aspiration that Dublin will have no homeless people by 2010, I am not at all convinced. If that were achieved it would simply mean that nobody was sleeping on the streets. It is very difficult to provide service in the community for somebody living in the crowded and temporary conditions of a night shelter. The submission made by the Simon Community, with its very specific proposals for services for homeless people, needs to be fleshed out.

Previous attempts to restructure psychiatric services ended up with large numbers of psychiatrically-ill people on the streets. Almost paradoxically, the lack of adequate services and provision of supported housing for homeless people means that beds in acute psychiatric hospitals are often being used improperly by homeless people who, literally, have nowhere else to go.

The Simon Community's submission contained the hair-raising story about the person who, having been discharged from a hospital, arrived at a Simon hostel with an intravenous drip still in place. All large organisations make mistakes. However, fundamentally they are holding up beds because they have nowhere else to go. If they are discharged improperly they will simply be recycled back in. A disproportionate number of homeless people end up returning again and again to acute psychiatric hospitals.

The report contains the bones of a wonderful service. We need proper management by people who are prepared to manage in terms of what is right and not what is easy. We also need proper structures for the multidisciplinary teams. We need to continue to identify niches in the community, for example, homeless people and those who are both mentally ill and have substance abuse problems. For each of those a very specific service needs to be established, supported and maintained, even when money might become scarce. It is very easy to cut back on services for those living on the streets, as they will hardly be parading to Leinster House or voting in the next general election.

Tim O'Malley (Minister of State, Department of Health and Children; Limerick East, Progressive Democrats)
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I thank all the Senators for contributing to a very good discussion on the Government's policy document, A Vision for Change. The contributions were very well informed. While I cannot comment on everything I have heard I will try to comment on some of it. One of the differences between this report and the last one, Planning for the Future, is that this report specifies an implementation body and a monitoring body, both of which are required to report on an annual basis, which will help.

It is not true to say the 1984 document was not implemented; much of it was. While it was not all implemented, much progress was made and much credit is due to the psychiatrists working in the sector. This area is complex and difficult and the psychiatrists should be thanked for the progress made. We are now moving forward and setting new goals. I take the point various speakers made about implementing and monitoring. The plan merely contains words; the implementation is what is important.

Many of the speakers referred to the community multidisciplinary teams. While in some areas the teams have been working very well, unfortunately in some other areas, owing to human nature, etc., the teams have not worked well. The structures did not exist and the group preparing the report placed a significant emphasis on team effort and people working together. This is one area that will be monitored. It is not beyond the competence of professional people to work together.

I believe Senator Lydon said that occupational therapists do much good work. The Mid-Western Regional Hospital in Limerick has very few occupational therapists. It is not a question of resources; it is as a result of decisions made by some vested interests. While I will not comment further that is the case. The same thing has happened in other areas around the country. People have asked about the lack of therapists, etc. I am not sure about the resolve of people to employ these therapists in the past. The Government has made decisions and many of these therapists are now being educated.

Speech and language therapists, occupational therapists and physiotherapists will not be coming forward for a few years but we are aware that there are many such professionals in other countries who could be brought here for a few years until we grow our own therapists, so to speak.

I agree with Senator Browne. When we talk about closing down the large hospitals, we are not suggesting that there will not be a small number of people who will need to be treated securely in a caring manner but it is a question of putting them into proper care. We realise we are talking about a small number of people who would be unable to live in the community. I share the Senator's concern, which is also real for many people, but I wish to allay it. I do not want the message to go out that people will take advantage of the vulnerability of a small number of people for other agendas. No speaker suggested that here this morning, nor am I suggesting it, but there will always be a need for small units for people who cannot be housed in the community.

On the funding issue, every speaker said we need more resources, something with which I agree. The report stated that there were adequate resources in some of the areas examined but the outcomes were not good. As well as having the resources, we must measure outcomes in future. That is stated in the report.

I agree with those Senators who spoke specifically about young adolescents and the lack of proper early interventions for them. That is something on which I intend to spend a good deal of time because I am aware, as were all the speakers in the debate, that if we intervene early with young people suffering from emotional problems — I prefer to use the term "emotional" rather than "psychiatric", and Senator Ryan covered that adequately — many problems that can occur later can be prevented. Much more needs to be done in that area.

I am glad Senator Ryan referred to the question of the sale of hospitals. The Government has given a commitment and the Cabinet has made a decision on funding but I have visited many hospitals and was very unhappy to see huge amounts of land surrounding some of them while at the same time the services being provided were appalling. People with mental health problems were living in appalling deprivation. What I am doing, and what the report recommends, is transferring those land assets to mental health assets. There is a commitment on the part of the Government to do that, and we will do it slowly. There is an assurance in this report that there is no question of dumping people into the community. I agree some incidents of that happened in the past. We will not revisit that but the people will be cared for properly before any institution is closed down.

Senator Ryan is right to concentrate on the homeless. I am looking at a particular model and have spoken to a few people in that regard. I would ask some of the Senators to think about this. I am not just selling land to the highest bidder. We have made mistakes in the past in that regard. If we are selling State assets and we need them for specific purposes, like the mental health area, we should consider inserting certain conditions. If 100 or 200 people have to be housed following the sale of a large institution, it should not be beyond our competence to devise a system whereby they can be housed in residential units in the area, with the rest of the land to be sold off. Some people have told me that is being done in other countries.

If we are selling the land we should control the end product, not developers. If it is sold to the highest bidder, the developer or speculator will do what he or she wants with the land and while we might get what people believe is a good price, we then have to buy other land to house the people concerned. I ask Senators to think about that and if they have any ideas to come back to me. It has not been done in this State yet but it is about time we did it, especially in this area because we are talking about social housing for many of these people with mental problems. Senator Ryan is right in that regard.

Many contributors to the debate raised the question of psychotherapy and counselling, an area in which I am interested. I agree that much important therapeutic work can be done in that area but we must tread carefully because there are charlatans operating who call themselves counsellors and psychotherapists but who are not qualified. There are also some great counsellors and psychotherapists. I have met many of these groups and they have now got together because they agree we must have proper standards. I met some of them again recently and they are making progress but we must tread carefully in this area. I mentioned the commitment on the part of the Department of Education and Science to ensure a sufficient number of such therapists are trained in the future.

I have dealt with the issue of the discharge of patients into the community. Proper places in residences in the community must be available before people can be discharged. The question of difficult to manage behaviour is dealt with in the report. It is an extremely difficult problem for the families, carers and loved ones of a young person exhibiting such behaviour but I hope we will get to grips with it.

Much progress can be made in the area of neuropsychiatry. Senator Lydon referred to chaplaincy. That is not mentioned in the report but there is no need to mention pastoral care. We are talking about counsellors and psychotherapists. Pastoral care comes under that heading and it would be wrong to mention it in the context of pastoral care as opposed to counselling. I have met many religious from all denominations who are doing great work in this area.

Senator Minihan raised a point about pharmacists. Speaking as a former practising pharmacist, I am somewhat critical of the profession for not being more of an independent voice monitoring the advent of hugely complex therapeutic new drugs. For years, Dermot Walsh, Inspector of Mental Hospitals, has commented on what is called polypharmacy. Many new drugs have come on the scene in the past several years but when people with mental or emotional problems are put on new treatments, they are reluctant to come off the drugs they are on, yet several others can be added to the patient's regime. We should examine that.

Forensic psychiatry is an area very close to my heart. It has been sadly neglected in the past. I would like to correct Senator Henry on one point. Her understanding was that the decision to close Dundrum was based on the fact that it was an extremely valuable site. I reiterate that a committee of all the users and providers of services in Dundrum was set up several years ago to examine all the options concerning Dundrum, including whether to remain on the site, move part of the site or move to a greenfield site. Its decision was to move to a greenfield site, although it did not specify a location. The Government has adopted that decision and we will move forward with a new central mental hospital.

I understand people's scepticism about this report. Even objective people and the voluntary agencies have been very supportive of it. However, the scepticism is understandable because in the past many reports were left to gather dust and not implemented. Like all the Senators that have spoken in the House today, I have an interest in this area. I will continue to raise the bar in this area. Not alone is this right, but it is something we have to do for the sake of society. It is not right that people with mental illness should be treated any differently from those with physical illness. The report is compiled by 18 individuals who do not represent associations or professions. I understand there were very robust discussions, but once the working group was set up I never got involved. There were disagreements, but at least they signed off on the report.

Implementation will be challenging, not just in terms of the Government coming up with the resources. It will also be challenging for many of the professions involved to change their ways. The changing of attitudes and how they do things can often be a bigger challenge for people. We have the report, it is Government policy and it is up to us to implement it. I thank the Members for their contributions. General acceptance of the report has been very positive. However, there will be small groups of people who will pursue their own vested interests. I am aware of one incident already in County Cork about people moving out into the community as well as other developments where efforts are being made to put people into proper residential care. People will come up with reasons these things cannot be done.

We, as elected representatives, must ensure this Government policy is implemented.

Mary Henry (Independent)
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That concludes the statements on the national policy framework for the mental health services. When is it proposed to sit again?

Photo of Pat MoylanPat Moylan (Fianna Fail)
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At 2.30 p.m. next Wednesday, 15 February 2006.