Seanad debates

Thursday, 19 October 2006

Mental Health Commission Report 2005: Statements

 

11:00 am

Tim O'Malley (Minister of State, Department of Health and Children; Limerick East, Progressive Democrats)
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I welcome the publication of the Annual Report of the Mental Health Commission 2005, which includes the report of the Inspector of Mental Health Services. The report relates to the year 2005. I acknowledge the important role the Mental Health Commission and the inspectorate play in providing an accurate and detailed account of services in the mental health sector.

The Mental Health Commission was established in April 2002 under the provisions of the Mental Health Act 2001. The Act is a most significant item of legislation and its purpose is twofold. First, it provides a modern framework within which people who are mentally disordered and who need treatment or protection — either in their own interest or in the interest of others — can be cared for and treated. In this regard, the Act brings our legislation in respect of the detention of mentally disordered patients into conformity with the European Convention on the Protection of Human Rights and Fundamental Freedoms. The second purpose of the Act is to put in place mechanisms by which the standards of care and treatment in our mental health services can be monitored, inspected and regulated.

The Mental Health Commission is the main vehicle for the implementation of the provisions of the Mental Health Act 2001. The commission has 13 members, including a practising barrister, three registered medical practitioners, of which two are consultant psychiatrists, two representatives of the nursing profession, a social worker, a psychologist, a representative of the general public and three representatives of voluntary bodies promoting the interest of people suffering from mental illness, of whom two have suffered mental illness in the past.

During 2005, the Mental Health Commission completed an extensive programme of work related to the commencement of Parts 2, 4, 5 and 6 of the Mental Health Act 2001. Part 2 deals with the procedures related to involuntary admissions, Part 4 covers treatment issues such as consent to treatment, rules for treatment, etc., Part 5 related to regulations and registration of approved centres and Part 6 deals with rules related to seclusion, bodily restraint and transitional arrangements. I am happy to inform the House that all remaining provisions of the Mental Health Act 2001 will be commenced on 1 November 2006. This includes the establishment of the mental health tribunals and provides for the commission to be the registration authority for all hospitals and in-patient facilities providing psychiatric care and treatment. One of the principal responsibilities of the Mental Health Commission is to promote and foster high standards and good practice in the delivery of mental health services.

The Mental Health Act 2001 requires the Inspector of Mental Health Services to visit and inspect every approved centre each year and, as he or she thinks appropriate, any other premises where mental health services are provided. This includes community residences, day centres and acute inpatient facilities. The inspector is then required to carry out a review of mental health services in the State and to furnish a report in writing to the Mental Health Commission.

The inspector's review of the services, including reports of inspections carried out, is published with the Mental Health Commission's annual report and is laid before both Houses of the Oireachtas. The inspector's annual report informs the commission, the Minister for Health and Children and all interested parties on the current state of affairs within the mental health services. In carrying out their inspections, the inspectorate paid special attention to care planning, how multidisciplinary teams were resourced, how they functioned, the therapies available, activities provided for service users, the physical environment and the management of such units.

The inspectorate believes, in common with good practice, that individual care plans are the basis for care and treatment provided that service users are actively involved, each service user has a key worker and the care plans reflect multidisciplinary assessment and treatment inputs. This is in line with the principles outlined in the new national policy framework for the mental health services, A Vision for Change, which was published on 24 January 2006.

A Vision for Change was developed by the expert group on mental health policy and has been accepted by the Government as the basis for the future development of mental health policy. The report outlines a vision of the future for mental health services and sets out a framework for action to achieve it in the next seven to ten years. The core principle underlying this policy is that people suffering from any form of ill health should be enabled to live as independently as possible. The inspectorate was concerned about the physical environment in some hospitals, the lack of proper care planning and the lack of therapeutic activities for inpatients.

The inspectorate was especially interested in the service provided to people who are resident in long-stay wards in large psychiatric hospitals. A total of 95 such wards, accommodating approximately 1,800 people, still remain in large psychiatric hospitals nationwide, all of which were inspected in 2005. The inspector's view is that it is unacceptable that patients continue to be admitted to long-stay wards. However, the inspectorate stressed that even in those wards in which conditions were poor, nursing staff were making enormous efforts to care for patients and provide appropriate activities.

The report of the expert group on mental health policy, A Vision for Change, recommends that plans should be drawn up for the closure of all mental hospitals. The expert group's report noted:

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.

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 the policy document, Planning for the Future, in 1984. A great deal of progress has been achieved since and the number of acute psychiatric units in general hospitals has increased from eight in 1984 to 24 at present.

A Vision for Change emphasises that this process should take place on a phased basis with the sequential closing of wards. It emphasises that hospitals can only close when the clinical needs of the remaining patients have been addressed in more appropriate settings. A Vision for Change 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. It recommends a person-centred treatment approach that addresses each element through an integrated care plan that reflects best practice and, most importantly, has evolved with the agreement of both service users and their carers.

One of the fundamental principles of the report is that of recovery, in the sense that people with mental illness can and should be facilitated in reclaiming their lives and becoming involved in society. To achieve this objective, people need both supportive mental health services and communities in which actions are taken to address basic needs such as housing, employment and education.

I am committed to the provision of quality care in the area of mental health, to upholding the civil and human rights of those who suffer from mental illness and to encouraging measures aimed at combating the stigma that is often associated with such illness. During my term of office as Minister of State with special responsibility for mental health, I have endeavoured to continue to accelerate the growth in more appropriate care facilities for people with a mental illness through the further development of community-based facilities nationwide.

The inspector refers to the continuing need to develop specialist psychiatric services. The need for such services has been recognised for some time and substantial progress has been made to establish them. As for child and adolescent psychiatric services, it is accepted that with the increasing pressures on young people, there is a need to improve responses to their mental health needs.

As I stated previously, the full provisions of the Mental Health Act 2001 will come into force from 1 November 2006. The Act defines a child to be anyone under 18, which brings mental health law in line with other Irish legislation. While very small numbers of children require involuntary admission due to mental illness, we have an obligation to provide the highest standards of care and treatment to this vulnerable group. It is accepted that additional beds for the treatment of children are needed and work is continuing towards ensuring that appropriate child and adolescent psychiatric inpatient services will be put in place without delay.

The Health Service Executive, HSE, established a working group on child and adolescent mental health services. The group consisted of representatives from the Irish College of Psychiatrists, the Irish Hospital Consultants Association, the Irish Medical Organisation, senior HSE managers and practitioners. The group explored options capable of creating immediate additional capacity for the regional provision of inpatient facilities for those children and adolescents who require involuntary admission under section 25 of the Mental Health Act 2001. The group's report has been adopted by the HSE.

The report proposes how services can be best delivered in an integrated and holistic manner and has identified additional inpatient bed capacity for children and adolescents. Each of the four HSE regions will identify three to four beds in adult units for the treatment of children and adolescents on an interim basis, pending the provision of dedicated units. Each unit will be supported by a consultant-led child and adolescent multidisciplinary team. Staff in such units will receive additional training and appropriate clearance.

Eight additional consultant-led child and adolescent psychiatric teams per year will be established nationally for the next four years to enhance community and inpatient services. This year, the HSE has allocated an additional €3.25 million for this purpose and recruitment is under way. This constitutes a significant commitment to child and adolescent services. The House will agree that the full implementation of the Mental Health Act from 1 November 2006 is to be welcomed as this will provide much needed protection to all adults and children who are involuntarily detained without further delay.

Recently, there has been increased recognition of the need to address mental health as an integral part of improving overall health and well-being. Mental health is now accepted as being as important as physical health as poor mental health has a significant impact on people's quality of life and their contribution to society.

The promotion of positive mental health is a broad concept that emphasises the improvement of the psychological health and well-being of individuals, families and communities. Rather than pertaining to mental health problems, it focuses on the promotion of positive mental health for all. It is important to note that responsibility for the promotion of positive mental health does not rest solely with the health services. It also should be part of daily life in schools, at work and in the wider community. Most health promotion initiatives, such as the encouragement of physical activity, also include an element of mental health promotion.

A Vision for Change also recognises the importance of promoting positive mental health and calls for the availability of mental health promotion initiatives for all age groups to enhance the protective factors and decrease risk factors for developing mental health problems. More specific recommendations identified particular age groups, treatment and community settings for the increased promotion of positive mental health.

In a previous report, the inspectorate recommended that the plans to relocate the Central Mental Hospital to a new, purpose-designed building should progress as quickly as possibly. I am happy to inform the House that the Government gave approval on 16 May for the development of a new Central Mental Hospital to be built on the site set aside for that purpose at Thornton Hall, County Dublin. The new hospital is to be built on its own campus, adjacent to the planned Mountjoy Prison replacement complex. It will retain its identity as a separate, therapeutic health facility owned and managed by the Health Service Executive.

The Central Mental Hospital is a national tertiary service and is the only centre in the State providing psychiatric treatment in conditions of maximum and medium security. The hospital provides acute psychiatric in-patient care to mentally disordered offenders including both sentenced and remand prisoners.

The Government has agreed that a new governance structure will be put in place for the Central Mental Hospital in advance of its move to the new site. It is proposed that a board of directors for the hospital be appointed following consultation with the Health Service Executive and other relevant stakeholders. The Government has also agreed that the development will be funded from the sale of the existing hospital site at Dundrum. Any balance of funds remaining after the completion of the new hospital will be available for re-investment in the health services, in particular for capital developments in the mental health services.

I wish to acknowledge the commitment of the commission members, the management and administrative staff and the inspectorate team. I thank the House for affording me the time to speak on the 2005 Annual Report of the Mental Health Commission, including the report of the Inspector of Mental Health Services.

Mary Henry (Independent)
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I thank Senator Browne for allowing me to speak first on this issue. The commission approached its new position in a most energetic manner and brought forward a strategic plan for 2004-05 which has six priorities. These are to establish the management, professional and organisational systems and infrastructure which will enable the commission to fulfil its statutory responsibilities; to promote and implement best standards of care within the mental health services; to promote and protect the rights and welfare of persons availing of mental health services as defined in the Mental Health Act 2001; to promote and enhance knowledge and research on mental health services and treatment interventions; to increase public awareness and interest in the mental health services; and to provide an efficient, responsible, quality service for customers. The commission has tried to address this.

There is a great deal of information in this report, but there is still a considerable amount missing on the issue of mental health in this country. We have information on the huge decrease in beds; in 1963 there were 20,000 people in mental hospitals and this was reduced to just over 3,500 by November 2005. There are around 4,000 beds available, which is approximately 131 beds per 100,000 of the population over 16 years of age. In the Dublin region the figure falls to approximately 63 beds per 100,000 of the population over 16 years of age. I do not know if this is an adequate number of beds. It is more or less in line with the international average, however, in this country there is a propensity to admit patients and, naturally, they should be as near as possible to their families.

The Minister of State pointed out that there are now beds in 24 acute hospitals, as opposed to eight, which was the case in 1984 when Planning for the Future was introduced. This is a welcome change because it helps remove the stigma attached to separate mental hospitals and allows the patients in question be admitted to ordinary hospitals. The inspectorate interviewed service users in the report and they said they did not like being admitted through general accident and emergency units if they were already known to be users of facilities within a hospital. Dr. Margot Wrigley, in a press release on behalf of the Irish Hospital Consultants Association, complained of a teenager who spent more than 24 hours on a trolley in an accident and emergency department despite the fact that he was acutely psychiatrically ill. We must watch the admissions procedure used in such cases because it is bad enough to sit in the accident and emergency department with a Colles fracture but it is far more difficult to sit there during an acute psychotic episode.

The Inspector of Mental Hospitals complains that some people admitted to general psychiatric hospitals are not admitted to admission wards but to long stay wards. This is unsuitable and must be very disturbing for some. Some 30% of those admitted to psychiatric hospitals have not previously been admitted to such a facility and many people recover and are not readmitted. Admission to a long stay ward is not suitable and I support the inspector's concerns on this issue.

The Minister of State raised the matter of children being admitted to adult psychiatric hospitals and I have spoken on this issue often in my time in the House. It is deplorable that facilities for in-patient admissions of children have improved so little; there are 20 or 30 such beds in the country. The admission of children is unusual but the admission of adolescents is more common. Serious mental illnesses can develop in adolescents and we must be in a position to deal with such cases. We must be even prepared to deal with serious cases of eating disorders.

Making three or four beds available in an adult psychiatric hospitals is not suitable, they need to be segregated. Even if children are not in separate hospitals they should be in separate units where they have facilities for play, education and so on. I spoke to a young woman who was treated in a mental hospital in the same ward as Fr. Brendan Smith, though she did not sleep there. He was subsequently charged with the sexual abuse of children.

I am anxious to discuss the 240 individuals who became long-term patients in 2005, which means each was in a mental health facility for more than a year. Mental health treatment has made much progress and it is worrying to read this statistic. Half of those patients were in five of the major psychiatric hospitals and we must be careful not to develop a pool of long-term patients in the older psychiatric institutions. We have received complaints in the Joint Committee on Health and Children regarding those in long-term psychiatric hospital care with few people to speak on their behalf. They are all in the older facilities and they need our help.

I am pleased to see more effort being made to seek the views of service users. There is a good section on this in the report and the inspectorate interviewed people in the Irish advocacy network who speak on behalf of people in psychiatric hospitals. The Central Mental Hospital was mentioned and I am pleased at the efforts that have been made by the relations and friends of patients there to get the conditions improved. This would not have happened without their help. It is regrettable the hospital is to be used as a major financial cash cow to fund the new institution in Thornton Hall because it is internationally agreed it is foolish to locate hospitals and prisons adjacent to each other. That is not considered good practice, but now is not the time for talking about that.

Service users everywhere appear to have the same complaints. Patients do not receive information, they are given little choice about their care plans and frequently do not get much by way of diagnoses from their psychiatrists. Often they have difficulty in understanding what is being said. They are not adequately informed about their medication or its side effects. The Minister of State will be well aware from his professional experience that there can be serious side effects from anti-psychotic drugs, neuroleptics and so forth. It is not right that patients are not being made aware of this. Also, they are angry that frequently alternatives to medication are not offered. We know there is very little talk therapy, psychoanalysis or counselling in many institutions and in many psychiatric facilities within the community. There are complaints about doors being locked unnecessarily. This humiliates people and it is an issue that has to be addressed. Smokers complain about the lack of facilities for smoking indoors. Another serious issue is the lack of suitable placements on discharge. I appeal to people not to object to planning permissions for facilities in their areas for discharged psychiatric patients. One in four of us is likely to experience psychiatric illness at some time and the majority of patients make a very good recovery. These are people who share the community with us, and we should behave in a better manner. Many patients experience difficulty getting follow-up care because of the distance they live from the institution, and there is also a lack of support for their families.

Involuntary admissions is a thorny issue. There were 2,830 such admissions last year, a small reduction on the previous year but still high by international standards. This is traumatic for both the patients and those who must have them admitted, be they family, friends, doctors or whoever. We must try to reduce the number of involuntary admissions. Another serious issue concerns patients who are regraded from voluntary to involuntary admissions within hospitals, and no data are included. We need this information.

Approximately 60% of patients involuntarily admitted are men; the gender difference is noteworthy. Men are inclined to experience the more serious illnesses such as schizophrenia, psychotic episodes and so forth, but one must also consider that frequently they are single people, with fewer family members, peers and social support. Can we not do more for these people? The tribunals are not in place yet. Have we got sufficient independent psychiatrists to give second opinions? We certainly cannot rely on people who work in the same hospitals. We are all aware of the difficulty experienced in securing independent advice in relation to the Neary case in Drogheda. That cannot be allowed to happen again.

We know from international reports that patients who are intellectually disabled have a high incidence of mental health problems. The inspector is scathing on this issue. There are only two facilities in the country, namely, Stewart's Hospital and St. Joseph's Unit in St. Ita's Hospital, Portrane, suitable for patients who are intellectually disabled and have mental illness. We talked on the Order of Business about the lack of inspection of nursing homes for the elderly. The lack of inspection of facilities for the intellectually disabled is unacceptable. The majority of them are non-statutory or voluntary institutions, and while great credit is due to those involved in running them, the inspector's report indicates that a great deal more needs to be done by way of inspection. The report states that if patients in some of these institutions had individual assessment — it is dreadful to think people are being mass assessed — approximately 50% would be found to have a mental illness. This is terrible and many of them are on long-term medication which it appears was not being reviewed frequently enough. The report had similar criticisms of the facilities for the elderly with mental illness and, as regards the places described as community centres for those discharged, it stated these places could not be regarded as proper community care. The people are in wards of 20 to 30, which could just as easily have been described as long-stay wards out in the community. We must not congratulate ourselves for having moved people out of large hospitals when they are not in adequate facilities. The number of beds for such people will have to be reviewed. There are not enough beds in the psychiatric sector and there is a lack of resources for treating people in the community.

The primary care strategy was introduced under the remit of the former Minister for Health and Children, Deputy Martin. How many primary care teams have been set up? It is laughable, but there are scarcely half a dozen in the country. These were to be the panacea for everything, with psychologists and so forth available to people in the community. General practitioners were to be able to refer patients immediately to such centres. A considerable number of children with behavioural disorders are not treated until they are teenagers, when they may have developed serious psychotic problems. What we have set up outside the major hospitals may not be adequate.

I congratulate all those involved in compiling this report and I hope we take seriously its weightier criticisms.

12:00 pm

Photo of Camillus GlynnCamillus Glynn (Fianna Fail)
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I welcome the Minister of State and the opportunity to speak on the annual report of the Mental Health Commission and the report of the Inspector of Mental Health Services. It has been a significant year for mental health in many ways. The Minister of State touched on this in the course of his contribution.

I welcome, in particular, the additional resources devolved to the psychiatric services, despite the fact that the sector was coming from a low base. I compliment the Minister of State because since his appointment, with special responsibility for mental health services, he has thrown himself body and soul into the job. The provision of these additional resources is in no small way due to the efforts he has made.

I listened attentively to the Minister of State's speech and to Senator Henry — I agree with much of what she said. The Minister of State spoke about the large number of old style psychiatric hospitals that remain. He said the inspector's view is that the continued admittance of patients to long-stay wards is unacceptable. I am not disagreeing with the inspector other than to say that in some cases where people were regularly admitted to a psychiatric institution, they would be admitted straight to a long-stay ward and not an acute one. Even were they to be admitted to an acute ward, they would soon be referred to a long-stay one. This could happen for a number of reasons, not least pressure on beds.

The report did not make reference to inappropriate bed occupancy. The House has debated this issue on a number of occasions. I recall that Senators Norris and Quinn tabled a motion on inappropriate bed occupancy in the last Seanad. I understand that this is still a feature and I would like to see it discontinued. We must bear in mind that psychiatric hospitals are not hostels. If there is a lack of facilities for homeless people, I do not see psychiatric beds as filling in for them. This is not an option and it should be discontinued forthwith.

The inspectorate said that even in wards where conditions were poor, nursing staff were making enormous efforts to care for patients and provide appropriate activities. That is most welcome. I would have liked the inspectorate's report to contain a few paragraphs dealing with the issue of visitation, especially for long-stay patients. I have previously made this point on another issue and I have not changed my mind. With the advantage of many years of experience, I have seen people who stopped getting visitors after a period of time. The isolation of people in long-stay institutions, psychiatric or otherwise, contributes to institutionalisation. When contact with the outside world discontinues, the patients will make themselves at home in their institutional surroundings. This is not a good thing by any standard.

As the Minister of State has said, a great deal of progress has been achieved since the publication of Planning for the Future in 1984. If memory serves, this was introduced by Mr. Liam Flanagan. I was pleased to hear the Minister of State say that greater resources will be provided for securing community-based facilities. Large psychiatric hospitals have served their purpose and every one of them should be closed. However, when one door is closed another one to a better facility must be opened. When established psychiatric institutions are closed, it must be borne in mind that in each of them a ward or unit was specially provided for people with challenging behaviour. Units are also needed for people who would not normally be resident in an acute ward — their behaviour may not be so challenging but they may have other illnesses.

The number of acute psychiatric units in general hospitals has increased from eight in 1984 to 24 today. It is time that we fast-tracked the completion of psychiatric units in all general hospitals. My local hospital in Mullingar is an example; it will get a psychiatric unit in the second part of phase 2B. Senator Henry was correct in stressing the importance of providing child and adolescent psychiatry units in all hospitals, even in ones that do not currently have a psychiatric unit.

The idea behind providing acute units to general hospitals is to demonstrate that psychiatric illness is an illness, and that psychiatric nursing and medicine are disciplines in their own rights. Why should there be a separate facility for psychiatric illness? This was one of the main contributors to the stigma surrounding psychiatric illness. However, were the truth to be told — and it is not often told when referring to the incidence of psychiatric illness in families — many people would be revealed as having psychiatric illness. I state this only as an established fact and not to glory in it.

In his contribution, the Minister of State said, "During my term of office as Minister of State with special responsibility for mental health, I am endeavouring to continue to accelerate the growth in more appropriate care facilities for people with a mental illness through the further development of community-based facilities throughout the country". This important statement is one of the central themes of this debate. It has long been acknowledged that community-based services are better. However, they are more expensive. I remember the time when community-services ceased at 5 p.m. on Friday evenings and did not resume until 9 a.m. on Monday mornings. Thankfully, we have seen the last of those days. Why were they closed? They were closed because the service was resource driven. Of course, one could say that the service was not driven because of the lack of resources.

The Minister of State also said that eight additional consultant-led child and adolescent psychiatric teams per year will be established nationally for the next four years to enhance community and in-patient services. The provision of child and adolescent psychiatry services is an imperative. When considering the vexed issue of suicide — especially among young males for whom the incidence of suicide is seven times that of young females — it is clear that this is an area on which we must focus.

I echo Senator Henry's comments on moving the Central Mental Hospital to a new site. From what I hear, it will be a flagship development and it is so important that words cannot describe it. I welcome it.

When we speak of health, psychiatric or otherwise, it is important to remember that we all have responsibility for our own health. Psychiatric health is equally important as any other part of our well-being and should be looked after. There is a difficulty with psychiatric illness because, in many cases, there is a lack of insight into one's condition. This can be a problem not alone for the carers, but also for the person in receipt of care. The 2001 Act is coming on stream, which is important. Many people have been critical of it, which is fair, but if it is constructive criticism we have to welcome it.

Regarding involuntary admissions, I welcome the tribunals, which are necessary. The loss of freedom for any reason, however, is a traumatic experience for any individual. That does not exclude people who have a psychiatric illness but there are people who, because of the nature of their illnesses, will need to be involuntarily admitted. Regardless of whether we believe that, it is the case.

I made a comment on the Order of Business regarding the visiting committees. As somebody who served in the psychiatric profession for many years, was a member and a chairman of a health board for many years and was on numerous visiting committees, I believe it is vital we consider the re-establishment of the visiting committees. The reason for that is simple. They have a therapeutic value, especially for the residents, because they recognise, say, the Minister in his capacity as a local authority member, myself, Senator Browne or any other public representative and there is interaction. It is a contact with somebody they know, a friendly face. That is very important to them. I have always held that view and nothing in the interim has changed my mind.

We are having a strong debate in a sub-committee of the Oireachtas Joint Committee on Health and Children on the use of pharmaceuticals. I agree with the necessity to have that debate. Questions arise regarding the use of certain pharmaceuticals, especially in the psychiatric services, and there is an urgent need to provide care and alternative treatment vis-À-vis psychotherapy, psychoanalysis, occupational therapy, which service has been in place for some time, and the other services that pertain to treatment that have a non-medical basis.

Regarding the Mental Health Commission's report for 2005, which includes the report of the Inspector of Mental Hospitals, since the Mental Health Commission was established in 2002 it has made an important contribution to the continued improvement of services for people with mental illness. The report highlights a number of areas that are of continued concern in mental health services, namely, the standard of long-stay accommodation for people with severe and enduring illness and the need for multi-disciplinary teams to support the people in the community. That aspect has been addressed but I ask the Minister of State, who appears to be good at getting his hands on additional resources — it seems to be a particular talent of his — to expedite that in whatever way he can to ensure the facilities for long-stay residents of our psychiatric institutions are improved and the fast-tracking of the acute units in the general hospitals. That is imperative.

I am delighted to hear the multi-disciplinary teams are being brought on-stream and will be increased in the next four years at the rate stated in the Minister of State's contribution. Tá mé fíorbhuíoch den Leas-Chathaoirleach agus den Aire. Comhghairdeachas aríst.

Photo of Brendan RyanBrendan Ryan (Labour)
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Cuirim fáilte roimh an Aire. One should say at the outset that there is no disputing the enthusiasm and commitment the Minister of State has brought to the debate. I may have some negative comments to make about the outcomes of his enthusiasm and commitment but, as Senator Henry said some years ago, she believed he was the first Minister with responsibility for mental health who visited the Central Mental Hospital in Dundrum. I was never one to argue with Senator Henry's authority on these matters. That he is the first Minister to do so is to his credit and to the shame of all his predecessors of whatever political party, and I say that without attempting to defend any Minister. From time to time, people in the voluntary sector who were occasional visitors to that hospital had stories about the necessary conditions imposed on the staff there because of the unsatisfactory physical environment. That was in spite of the considerable commitment of people who work there.

Apart from controversies about how much was paid for the site and various other issues, while I can accept a certain logic to the juxtaposition of the Central Mental Hospital and the new prison, the convenience of the prison service ought not to impact on the design, layout or access to the hospital. For instance, there should be two separate entrances. Apart from the physical juxtaposition there should be no reason for anybody who has a family member or loved one in the Central Mental Hospital to have any sense that he or she is in an area of security, other than the security of their loved ones, or to have any sense of having to get special permissions to visit.

I know the Department of Justice, Equality and Law Reform too well not to believe that, shortly after this process starts, it will identify the Central Mental Hospital as a potential vulnerability in the security of the prison and introduce a system to check people in the interests of the security of the prison. It may come after, for instance, some security issue in the prison which may turn out to have a connection between the prison and the Central Mental Hospital. I do not have an argument in principle with that, although many do. People are of the view that this stigmatises people but that not need be the case. Geographical adjacency should not necessarily stigmatise, but I have a genuine concern that does not relate to the position of the Minster for Health and Children or the Health Service Executive. I have experience over many years of the all-embracing focus on absolute security of the Department of Justice, Equality and Law Reform, which has been transferred to the Prison Service, and which I believe is a danger to what the Minister wants to do.

I would argue that there should be a statutory basis for the independence of the Central Mental Hospital and the new prison. It should be written down and made clear that the Department of Justice, Equality and Law Reform cannot impose security conditions which would be different from those that would otherwise be required in a high security mental hospital. Otherwise, I can guarantee that — perhaps not in his time as Minister, which might not be very long, or even in my time as a Senator, which might not be much longer — if there are two adjacant buildings with a considerable and inevitable movement of people between them, the Department of Justice, Equality and Law Reform will try to take over the way the process is controlled. It is in its nature to do so and that will be the case, unless the law states unequivocally that it cannot do it. If any room for manoeuvre is left to the Department of Justice, Equality and Law Reform, we will have a security fence around the entire complex within 20 years. I guarantee that will happen. There are good reasons the two units should be close to each other, mainly to do with the well-being of individuals and the possibility of overlap of services etc. but I guarantee that unless it is written down in explicit terms, the Department of Justice, Equality and Law Reform will end up being the determinant of what is appropriate and a security fence will be put up that will have to be breached by every visitor visiting a family member in the Central Mental Hospital. That is not what the Government, the Department of Health and Children or anyone wants but it will happen. It is difficult to reconcile the excessively congratulatory and upbeat tone of the commission and the carefully worded, extraordinarily serious criticisms of the inspector.

I have an interest in this area because my wife is a consultant psychiatrist. I must choose my words carefully because I am answerable to a critic far more formidable than any Member of this House. The views I express are my own and should not be attributed to anyone else. In the past I have made comments about schools my children attended. Subsequently, I discovered that senior officials at the Department of Education and Science contacted the schools when they should not have done so. I do not want that to arise. I will quote only from what is in the public domain.

The situation of children remains far from satisfactory. They should not be in adult psychiatric wards. The Mental Health Act was passed in 2001. That a solution is now being found to a problem that existed for five years is not a good sign of the commitment and energy needed, which I believe the Minister of State has. This is far from satisfactory.

The situation of people with intellectual disability is described at length in the inspector's report. It states:

There is no HSE Region in the State with an acceptable level of service for people with intellectual disability and mental illness. There are insufficient consultant posts in all regions, and those posts that do exist have no multidisciplinary teams associated with them.

Does the Government accept that this is factual and that services need to be set up? The report states:

Persons with intellectual disability and mental illness may be receiving care in settings that are not approved. There is no statutory inspection process for either community-based or institutional-based services for persons with intellectual disability. There is no national record of the levels of use of particular practices, such as restraint, seclusion or the use of medication without informed consent or against resistance.

I do not wish to politicise an issue when no Government of the past 30 years emerges with much credit.

Throughout the crises in the health services of the 1980s and the early 1990s, the practice of health boards was to save money in mental health services irrespective of the intent of central Government. This occurred because the last person who can publicly complain about the lack of a bed in a hospital is a person suffering with mental illness. Therefore it is easiest area in which one can make cutbacks.

According to the Minister of State, the Mental Health Act will be in force from 1 November. Have all issues with regard to nursing escorts and their legal liability, insurance position and training requirements been resolved? A "Yes" or "No" answer is needed.

There is differing information on the number of acute units in psychiatric hospitals that are locked at night or during the day. Have investigations been carried by the commission that have concluded by suggesting that doors be locked in case patients might escape? Is the commission recommending a practice that the inspector is attempting to eliminate? We must be clear on the precise status of the inspector vis-À-vis the commission. If the inspector of mental hospitals thinks a certain practice is wrong, is the commission free to ignore that opinion? That would be a disturbing possibility.

There is a need for people with mental illness to have access to more than psychotropic drugs or pharmacological treatment. Are we encountering bottlenecks in respect of the caseloads of people other than consultant psychiatrists? Is there evidence of this and what will the Government do?

On page 56 the report addresses the uneven nature of funding. I will be provincial on this matter because the report states that Cork is underfunded by comparison with other regions of the country. That is the result of historical decisions of the health boards. If there is merit in the HSE it is that it provides a rational basis for funding. In that case, despite anomalies throughout the country, there cannot be a sixfold difference in per capita funding in different regions. The Minister and the HSE must address this problem and not in ten years' time. Funding can either be increased in some areas or reduced in others.

Why do involuntary admission rates vary by a factor of five or six around the country? It is not because there are more ill people in one region than another. It is a matter worthy of investigation. The area in which I have most family connections, south Lee, has one of the lowest rates of involuntary admission in the country.

I am concerned that hundreds of people are in psychiatric hospitals for more than five years. The long stay issue must be addressed. If one is in a hospital for more than five years it is acting as a hostel. It may have to be a high security hostel but it is a secure unit to protect the person or society and not a hospital. I am not sure our mental health services have improved. I thank the Acting Chairman for his indulgence and I thank the Minister of State for taking the time to listen. I am aware that he does listen, which is one of the reasons it is well worth participating in a debate such as this.

Photo of Michael KittMichael Kitt (Fianna Fail)
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I welcome the Minister of State to the House. I wish to share my time with Senator Feeney.

Photo of Labhrás Ó MurchúLabhrás Ó Murchú (Fianna Fail)
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Is that agreed? Agreed. Senators Kitt and Feeney have five minutes each.

Photo of Michael KittMichael Kitt (Fianna Fail)
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I am glad that Senator Ryan raised the issue of the development of the new central mental hospital at Thornton Hall. I am reassured by the Minister of State's comments in respect of the hospital having its own identity and a separate facility. This is very welcome.

He also made a point about the fact that children are sometimes treated in adult psychiatric wards. I find it difficult to believe this practice still exists. We have sufficient community residences to ensure this should not happen. This is one of the issues the Inspector of Mental Hospitals has raised. When the inspector visits hospitals, and I presume he visits community residences as well as hospitals, he inevitably makes the point that children should not be treated in adult wards.

It highlights the fact, which I have previously raised, that service providers such as the Brothers of Charity and the Galway County Association deserve more funding. They have informed me that they will be seeking funding for next year's services from the Minister of State. As other speakers have noted, the Minister of State has secured additional funding and I hope he can do so for these service providers. In the past when the old health board structure was in place, the money was divided in a very faulty way. A mathematical formula was found where one-half of the money went to Galway, one-third went to Mayo and one-sixth went to Roscommon. This is not the way in which money should be divided. It should be allocated on the basis of need and assessment. I would like to see this practice continue in the future.

I wish to raise the matter of St. Brigid's Hospital in Ballinasloe, which has a very good record in respect of the provision of services but which is being closed down slowly but surely, as the Minister of State is aware. Sites for industry have been located on the site, sporting bodies are seeking some recreational lands on it and the place is being wound down. There is concern that if property on the site continues to be sold, the money will be somehow diverted into services other than psychiatric services. Money should be ring-fenced for psychiatric services in east Galway and I hope the Minister of State can inform me at some stage that this will happen. The property is being sold off and it has been suggested that the money might be diverted to services other than psychiatric services, which should not happen.

Another very important issue relating to St. Brigid's Hospital is the question of what will happen to the staff when the hospital closes. We keep hearing that nothing can be agreed until everything is agreed, which does not provide the hospital staff with much certainty. I hope we can resolve the matter soon and put in place a deal for the staff in respect of matters such as redundancies and pensions.

I am very much in favour of community residences. As other speakers have noted, it is expensive to fund community residences because one is talking about admitting a large number of people from the hospital and finding accommodation for them, possibly throughout counties in the western region such as Galway, Mayo and Roscommon.

In particular, we should examine the services for people with alcohol problems. As the Minister is aware, St. Brigid's Hospital contained an alcoholic unit, as it was known, which has now closed. I always believed it was a good idea to have a unit for people with alcohol problems so that they could be taken out of their environment for their own sake and the sake of their families and spend some time in a residential unit. The new thinking appears to favour locating alcohol units and services in the community, but I do not believe it is always possible to do so. I am not convinced that it is the right thing to do in all cases. Some people need a residential service based in a hospital where they can be given some time, possibly less than a week, to deal with the problem they face. We must examine the issue of alcohol because, as we see from the figures, it is a very difficult issue with which to deal.

The subject of suicide has been mentioned.

Photo of Paddy BurkePaddy Burke (Fine Gael)
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I understand Senator Kitt wishes to share time with Senator Feeney.

Photo of Michael KittMichael Kitt (Fianna Fail)
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Yes. This year's budget and following budgets should contain additional funding for suicide prevention. I commend the Minister of State on what he has done and I hope he can secure the additional funding for disability and psychiatric services for next year.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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I thank Senator Kitt for sharing his time with me and I welcome the Minister of State back to the House. Senator Ryan is correct in saying that the Minister of State is a listening Minister. He is also a caring Minister whose brief suits him very well. I am delighted to have the opportunity to contribute to this debate.

I will focus on the annual report for 2005 of the Mental Health Commission. I was interested to discover that a line in it which stated that there are no autistic spectrum disorder services in Sligo because there is no consultant psychiatrist there. I was rather surprised to read this because Sligo possessed a wonderful child psychiatrist, Dr. David Tindall. He has since moved on but there is an acting post which has been filled. It is not a permanent one and I ask the Minister of State to ensure, if possible, that matters are moved along. Something like autism can be possibly picked up in the educational system rather than being addressed in the health system. Perhaps it would be better dealt with there.

I have always placed on record my interest in adolescent psychiatry. I remember telling a very sad story a few months ago about a 14 year old who was an inpatient in an adult unit. The consequences for him were very drastic. I am aware that a working group is seeking an interim solution to the problem of how to deal with those aged 16 to 18. At the moment, most of them probably end up in adult units. The Minister of State is a family man in addition to being the Minister of State with responsibility for mental health. Adult units are not suitable for these patients. There should be more dedicated places for adolescents.

It is great to see all the comment surrounding multidisciplinary teams. Everyone would support this. However, it is sometimes very difficult to put together this entire team. Sometimes a social worker, occupational therapist or psychologist will not be available and the team is not composed. More resources should be put into developing multidisciplinary teams.

In a debate such as this, I always look to my home base. I live in an old health board house in Sligo which was the home of a former HMS. My next door neighbour is St. Columba's Psychiatric Hospital, which is the mental hospital in Sligo. The service delivered by the hospital is second to none. It will state that it does not have sufficient resources and I will address this shortly. I spoke to professionals at the hospital this morning who are delivering this service and they informed me that if they were sick in the morning, they would not want to leave Sligo. They would wish to stay at home and be treated for their mental illness.

We have an excellent community-based service with inpatient facilities. It provides services such as an outpatients department, day care, a day hospital and domiciliary care, which takes place in patients' homes. It also has a dedicated psychiatry old age team, with which I was very impressed. I did not come across it before. This morning, I spoke to one of them about the fact that the Sligo and Leitrim area is the only part of the country where a cognitive behaviour therapist is assigned to every GP unit. That means when someone who does not need to be hospitalised goes to the doctor he or she can be assigned to the cognitive behaviour therapist and be treated for a short-term problem without drugs.

I also have praise for a cross-Border project on caring for carers, which may have concluded but is being continued in Sligo and Leitrim. It upskills carers who work with patients in their homes. The people availing of the service are happy with it.

At present, training for undergraduate psychiatric nursing is based in Letterkenny. St. Angela's is a very good educational facility in Sligo. Moves are afoot to bring cognitive behaviour therapy into the undergraduate programme. The good result yielded from the scheme running in Sligo make a case for including it.

I take my hat off to the mental health unit in Sligo. It sold the building it was based in 20 years ago and we now have a beautiful hotel in the old mental hospital. The mental health unit now only has an admission unit and a ten-bedded ward. If it had stayed where it was it may have received more because it would have been awarded a team enhancement grant at least, which may have provided three or four more social workers, a psychotherapist or a psychologist. Will the Minister of State consider providing for multi-disciplinary members of those teams rather than medical personnel?

Fergal Browne (Fine Gael)
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I wish to share my time with Senator Norris.

Photo of Paddy BurkePaddy Burke (Fine Gael)
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Is that agreed? Agreed.

Fergal Browne (Fine Gael)
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To clarify, as a spokesperson I have 15 minutes which will be divided as eight minutes and seven minutes.

Photo of Paddy BurkePaddy Burke (Fine Gael)
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Is that agreed? Agreed.

Fergal Browne (Fine Gael)
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I welcome the Minister of State and his officials to the House. I will not repeat what was stated by Senators Henry and Ryan and other speakers. I will summarise the issues raised by the Mental Health Commission report.

I had the privilege of sitting on the sub-committee of the Joint Committee on Health and Children which examined suicide. The report states suicide is responsible for three in ten deaths in the 15 to 24 year age group and is the highest cause of death in that age group. That is shocking. The report also states only four child and adolescent mental health teams are in place in the HSE south-eastern region although the population requires a minimum of eight teams.

Over a ten year period, the budget has been reduced from 11% to 7%, although I appreciate more money is being spent on health services. However, as we move away from large mental health institutions, pressure to match funding in other areas exists. We should not be tempted to cut funding. We should ring-fence a certain percentage of the budget every year to spend on mental health. We should not allow the matter to slip down the pecking order.

The report discusses the absence of lockable storage facilities and instances of theft taking place. It also states some wards have no locks on toilet or bathroom doors. The report also mentions inadequate sanitary conditions, leaking ceilings, damp, peeling paint and holes in walls. In terms of communication problems, the report states service users complain they do not receive adequate information on diagnosis, a lack of user involvement in drawing up care plans exists and insufficient information on patient rights and complaint procedures is provided.

The inspector's report makes reference to the fact that long-stay patients are cut off from society, friends, family and peer services. It also states the majority of 24-hour supervised units for people with mental illnesses are too large and a significant number of institutions are located in remote areas cut off from the community. The report also highlights a lack of suitable follow-up accommodation for people who have used 24-hour supervised units.

The report mentions a lack of places in the central mental hospital, which is the only high-security psychiatric hospital in Ireland. My colleague, Deputy Neville, who is a former Member of this House, continuously raises this issue. On 10 October, which is world mental health day, he raised the important aspect of human rights of patients with mental illness. The Government should not forget that area and it is vital we do all in our power to ensure people who require long-term and short-term mental health services are treated with the dignity they deserve.

Deputy Neville has also discussed the need for the national treatment purchase fund to be used to reduce the 12-month waiting list to receive psychiatric care. That seems to be a sensible suggestion. Will the Minister of State indicate whether the Government is in a position to take up that proposal? It is crazy to think someone needing help is expected to wait 12 months or longer.

I am frustrated by the fact that often we are restricted on what we can state on health because of a lack of knowledge through not receiving answers to the questions we ask. A counsellor who appeared before the sub-committee examining suicide raised the issue of the waiting list for adolescents. Afterwards, I asked the Minister for Health and Children about it but she was unable to give me the figures. We know a major problem exists, but we do not know how bad it is. We must work on that to enable us to do our jobs properly.

I was disturbed to read in last week's Sunday Independent that 15 mentally disturbed prisoners were awaiting treatment in the country's only high-security psychiatric hospital. They remain in various prisons while they wait to be admitted. The lack of prompt access to appropriate psychiatric services leads to more severe mental illnesses among prisoners. Executive director of the Irish Penal Reform Trust, Rick Lines, stated our prisons are becoming warehouses for people with mental illnesses. Waiting lists for admissions to the Central Mental Hospital have become the norm. Conditions at the Central Mental Hospital have been described as antiquated and three quarters of the patients treated there have gone through the courts system.

In his speech, the Minister of State made reference to the new complex due to be completed in 2010. What will we do during the next three and a half years? It might take longer to complete. Do we expect patients to put up with the same long waiting lists and the antiquated conditions?

A report in today's Irish Independent states 25,000 people are admitted to mental health hospitals every year, 8,000 of whom suffer from depression, and 70% are re-admissions. The Wellbeing Foundation makes the point that people suffering from depression need counselling and psychotherapy and not necessarily the services being offered. We must make the treatment relative to the needs of the patients and acknowledge depression is a major reason people are admitted to mental health institutions.

The report refers to individual hospitals and services. In one hospital in the HSE south area, the male admission ward is a locked ward and at the time of inspection had seven patients on temporary status. No policy on locking the door exists. Occasionally, children under 16 years of age are admitted as are people with moderate intellectual disability. There are frequent admissions for alcohol and drug detoxification and at the time of inspection six patients were undergoing detoxification. It is totally inappropriate that young people are mixed with not only adults but people with severe drug and alcohol problems.

Another paragraph reports that there are no therapeutic activities in the ward. Some patients go to the activation ward and there are frequent transfers of patients to other wards because of bed shortages. Patients complained of boredom and said the ward was too small. One patient complained about the lack of confidentiality due to the cramped nature of the ward. Another said that the nurses' office was centrally located and the walls of the office were open at the top so all conversations in the office could be heard in the dormitory.

In another case in the Dublin mid-Leinster region, the female admission ward is a locked 25 bed ward located on the first floor of the main psychiatric hospital. Eight patients awaiting alternative accommodation could be discharged if this was available. Access to a psychologist, occupational therapist or social work is by referral letter only, even within the multidisciplinary team. There are weekly multidisciplinary team meetings. Access to addiction counsellors is usually on discharge. The consultant psychiatrist and NCHD attend the ward daily and there is access to radiology and laboratory services. For medical and surgical assessments, patients must wait with staff, often for extended periods, in accident and emergency services in the general hospital. This can cause difficulties if the patient is disturbed and causes staff shortages on the ward.

I spoke to the Minister of State before about a particular case in Carlow and I acknowledge his help on that occasion. Recently, however, a mother came to me pleading about her 18 year old daughter, who was hitting her even while she was driving and has severe behavioural problems. That girl is unfortunately in Mountjoy Prison for six months but the mother is terrified of when she will be released. It became so bad the mother slept fully clothed holding her mobile phone and her car keys in case she was attacked by her daughter during the night. There is a huge gap in services for those in this situation. If one phoned for advice on where she could go, it was like pass the parcel in that no one knew but they always knew to refer her to someone else. No one took responsibility so I welcome the new policy formulated by Fine Gael and the Labour Party in this area.

I was amazed to find out that up to 11,000 people presented at accident and emergency wards following instances of self harm in 2003, with estimates that the figure could be as high as 60,000 incidents per year. We must talk about self harm and suicide in the same vein.

1:00 pm

Photo of David NorrisDavid Norris (Independent)
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I thank Senator Browne for sharing his time with me. This is an important opportunity for us to make statements and express views on the sensitive topic of mental health.

In the old days, people with mental difficulties were regarded as a pariah group. We should look with gratitude to that great figure, Dr. Jonathan Swift, Dean of St. Patrick's, who founded St. Patrick's Hospital. He made it clear there was such a thing as mental illness that was parallel to physical sickness and that no shame should attach to it. Prior to that, there was the Bedlam Hospital where people with mental illness were regarded as subhumans who could be taunted and provoked, who would foam at the mouth and entertain the visitors, a very callous view.

Despite changing attitudes, there is still a danger of stigmatisation, particularly an association between wickedness and crime and disease and illness. That is why I put the question of Thornton Hall at the forefront of my contribution. It is a move away from the situation we had with the Central Criminal Lunatic Asylum in Dundrum, a dreadful Dickensian place. I question the wisdom, however, of placing a mental hospital in the grounds of a prison because of the danger of association between the two institutions, both run by the State in the same grounds, which may form an association in the mind of the public. This is resented by those who access these services and I have been lobbied by both individuals and groups who feel this is very counterproductive, even though it may be efficient in terms of saving money. We must be careful we do not stigmatise this group of people.

We all have an interest in this because a report produced by Millward Brown makes the astonishing statement that nearly 70% of people in this country have some association with mental illness in respect of spouses, relatives and friends. This affects all of us.

There are novel approaches and I commend to the Minister of State the approach being taken in Trinity College. The Unilink initiative allows for people with a degree of mental illness or disability to enter third level education. It is marvellous to think that people are having their talents drawn out, that is what education really means. They receive help from mentors, staff and students, to cope with and manage their academic and social lives. This is being a good neighbour and I am proud that Trinity College has pioneered this and several other third level groups are doing the same. If we want to get people out into the community, this is a good way to do it.

Dr. Elizabeth Dunne, of the department of applied psychology in UCC, highlighted difficulties in a report published by the Mental Health Commission that surveyed people using the services. One of the main difficulties is time lag. If a person suffering from mental illness has a crisis, it is an immediate situation. One person indicated that he was very bad in May, asked to see a psychiatrist right away but was told he would have to wait until August.

A surprisingly high proportion of admissions were involuntary — 22% according to Dr. Dermot Walsh, former inspector of mental hospitals. It is, therefore, important to listen to the voice of those who have been through that experience. They recalled the experience as traumatic, involving inordinate force and, once they were in, they were suffocated by lack of privacy, exercise, fresh air and things to do if one does not smoke or watch television. We must take such criticism into account.

Young people are very vulnerable in a rapidly changing society in which gender roles are blurring and they can be easily confused. I support the move to provide an opportunity for young people to refer themselves without parental consent. Sometimes a young person in distress does not want the family involved because it may be the source of the trouble. Confidentiality is necessary. As Senator Browne pointed out, 11,000 present for self-harm in 2003 and we have a very high suicide rate.

We must act on what emerged in the recent survey on Irish attitudes to sexuality in The Irish Times. We do not have a proper education programme on the reality of sexuality, principally heterosexual but also with a component for young gay people who are subject to pressure. There is a multiplier in mental health statistics related to gay people.

There is also the problem of what happens to the young people who present themselves. There are only 20 beds in the State for young people and the system cannot cope. A doctor was quoted as saying that any time a colleague wants to admit a child, it is a huge issue for them because there are only 20 beds. She pointed out that the State has had five years to prepare for this. It is almost a cliché to cite cases involving the use of trolleys. In one case, however, a child was held for seven days on a trolley in an accident and emergency department. If a person in these circumstances has a pain, he or she will be able to put up with it and may even be distracted by all the fuss and bother taking place but this is the last thing a person with mental illness needs.

A further problem is the failure to implement certain aspects of the Planning for the Future document, published in 1984. The multidisciplinary team approach has still not been fully implemented 20 years after it was proposed. It must be completed.

Senator Browne referred to the poor physical environment in the mental health service. I found it heartening that, in parallel with criticism of places such as St. Ita's, in which we have all indulged for having peeling paint, blocked lavatories and poor conditions generally, the report pays tribute to nursing staff. I express my appreciation to the staff of mental health institutions who, in difficult circumstances and sometimes squalid conditions, provide wonderful standards of professionalism. It is for this reason I welcome the opportunity to give support to professional care workers in the area of mental health. The House will do all in its power to strengthen the hand of the Minister in securing access to extra funds and facilities and to ensure this vulnerable group of people is looked after.

Ireland has an unusually high rate of schizophrenia when placed in an international context. Several years ago, I was approached by Schizophrenia Ireland asking if it could link into Bloomsday. I agreed to its request and indicated I would provide any assistance I could because of James Joyce's daughter, Lucia. At that stage, Schizophrenia Ireland had not heard of Lucia Joyce but it subsequently designated 26 July Lucia Day. I will place on record the words of James Joyce who is often regarded as a cynical, distant man, a kind of remote, literary lion. In 1936 Joyce was spending money hand over fist to try to assist his daughter, Lucia. His friends started criticising him because of the expenditure. In a wonderful letter he wrote that he knew he was being criticised for spending "that precious metal", money, on trying to find a cure for "the most elusive disease known to man and unknown to medicine". Referring to his daughter, he added that if one were where she was and felt as she must, one would at least experience some hope if one knew one was neither abandoned nor forgotten. What a wonderful, humane letter and marvellous description of the mystery of mental illness, an illness known to man and, nowadays, only partially known to medicine.

Photo of Ann OrmondeAnn Ormonde (Fianna Fail)
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I welcome the Minister of State and wish him well. He has shown great sensitivity in dealing with the problem of mental health and the quality of mental health services. I was distracted by Senator Norris's beautiful quotation, from memory, of a letter written by James Joyce. I share the author's sentiments as we try to move on from the past.

This debate focuses on a vision for change for mental health services. The 2005 report of the Mental Health Commission seeks to ensure high standards are promoted and fostered in the delivery of mental health services and sets out how this can be done. As the Minister of State indicated, a strategic plan has been developed which sets out how best we can move from the old concept of mental health with which we all grew up. In the past, anybody who had a mental deficiency was immediately removed from society, placed in a mental institution and stigmatised for the rest of his or her life. I welcome the changes outlined in this report and the report of the Inspector of Mental Hospitals, including the new practice of carrying out inspections of mental health institutions and residential care centres in the community at 24 hours notice.

It is worthwhile to dwell on the determinants of a quality mental health service. One must be respectful and have empathy for the patient and those who provide the service. People must be made to feel important and the system must be community based, accessible, user friendly and must encourage user participation. The environment must respect the dignity of the individual and his or her carers and family. Leadership and a good, effective management system are necessary. High skilled, multidisciplinary teams must be in place and evaluations and reviews carried out. One cannot deviate from these determinants and if the Minister of State ensures they are implemented, Ireland will have a quality mental health service. My vision of change is one which focuses on keeping matters simple and tight.

I will focus on adolescents as they are an age group with which I am familiar. The Minister of State noted the requirement to recognise the need to address mental health as an integral part of improving overall health and wellbeing. I worked as a counsellor in a school. Considerable work must be done to get all the stakeholders working together. The fabric of society is crumbling around us and dysfunction is increasing. How do we handle a 14 year old from a dysfunctional background who takes drugs and suffers from depression? Teachers must be the first port of call in such circumstances. For this reason, we need a school programme that will detect problems and determine the best approach to referral. It may not be possible to assist the family. Multidisciplinary teams consisting of teachers, psychologists, psychiatrists, psychotherapists and counsellors do not appear to have been established. The National Educational Psychological Service, for example, is not yet fully up and running. When a problem arises, it is difficult to get a psychologist to come to a school to carry out an assessment.

Autism and attention deficit hyperactivity disorder, ADHD, and attention deficit disorder, ADD, are major problems which, if not detected on time, can result in the system breaking down. The kernel of the solution is to ensure stakeholders are brought together. It is not to be found in a pharmacy or by psychiatrists prescribing pills but in developing an integrated, holistic approach. In many cases, the problem lies in a person's lack of self-confidence when he or she withdraws into himself or herself in response to society's pressures. While it is widely accepted that places will be always needed for acute patients, locking people away and cutting off communication to the outside world is not necessary in the majority of cases.

A holistic approach is required. The Minister of State referred to the psychological health and wellbeing of individuals, families and communities. I welcome the shift towards a community centred approach in which everyone works together. It is time people in communities became aware of the problems around us and how best we can all play our part. It does not always have to be left to the professionals. We must be aware of where help is needed in a society and help families that need it. All stakeholders need to rethink the society of the future. That will help the delivery of good mental health care. I reiterate the determinants of good quality of service. If that is included in the vision of change for the future, the Minister will have done a marvellous job and I know that is his thinking.

Tim O'Malley (Minister of State, Department of Health and Children; Limerick East, Progressive Democrats)
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I thank the Senators for participating in an informed debate on mental health services as they evolve. We are discussing evolving services to a vulnerable section of our society. It is the responsibility of the Government and the Health Service Executive, HSE, to ensure that those who suffer from mental illness are the principal people in this reformation. Too often in the past they were not. Services evolved for other reasons. Anybody who knows anything about the mental health services knows exactly what I am talking about. Many points have been raised and I have only seven or eight minutes remaining, so I will try to answer some of the queries.

Senator Henry mentioned that in Ireland we have a propensity to send people to hospital. We must face the fact that of all European countries, Ireland, in spite of the wealth that has been created, has for many years had a propensity to hospitalise people with mental health difficulties. A new stream of thought must be brought into being by everybody involved in services for mental health patients.

According to the majority of expert opinion worldwide, 95% of people with depression and mental health difficulties can and should be treated in the community. That is different from the services we have evolved over time. I do not criticise what went before us because the knowledge did not exist. We must structurally and strategically place our services in a new model in the community to ensure patients get the best services for them and their families.

Senator Henry said people in long-term care need advocates. It is an indictment of our modern society that many people in long-term care for mental health difficulties have nobody to visit them. Fantastic work is done by those who advocate on behalf of such patients. People would do a wonderful service if they would become involved in community-based organisations such as Grow, Schizophrenia Ireland, Aware, Console and many more. They do fantastic work in the community and people who wish to help should get involved.

There have been several damning reports recently on the lack of information to patients about their medication and its side effects. I was delighted to hear Senator Glynn mention that this issue is of concern to the Joint Committee on Health and Children. I look forward to the committee's views on this area, about which I have great concern, as I have publicly said for many years. I have much experience in this area and have seen many bad practices evolve that I do not like. While I do not suggest that psychiatric medicines are unnecessary, they should not have the place they have in the treatment of people with mental illness. There is a major conference in Dublin this weekend, which I hope will bring much attention to this topic.

We had well-informed contributions from the Senators today, many of whom are members of the Joint Committee on Health and Children. I urge them to become involved in this area because it will be of serious concern to anybody involved in the treatment of people with mental illness and it behoves us all to listen. Although we try to be objective, we are all prejudiced by our life experiences when we discuss the treatment of people with mental illness. Much work has been done and it is time to listen to the patients. They have no prejudices. They are objective. They are telling us their stories of being on these potent drugs. We all have a responsibility to listen to them. I ask the members of the Joint Committee on Health and Children to take this matter seriously. I will be delighted to attend the committee to listen to them and participate in their debates.

While I do not have time to discuss all the issues raised by Senator Ryan, I take on board his well-made comments on design and the separate entrance and identity of the new Central Mental Hospital as a distinct complex. It is a new, state-of-the-art mental hospital under the jurisdiction of the Department of Health and Children. Project team members are studying hospitals throughout the world to ensure that when we replace the existing Central Mental Hospital, built more than 156 years ago in 1850, by moving to Thornton Hall, it will be not just physically new, but will embrace all the best in forensic psychiatry. I look forward to everybody working together to ensure that happens. I take on board Senator Ryan's well-made point that we must ensure it is a separate entity from the Department of Justice, Equality and Law Reform and the Prison Service.

Senator Ryan and others mentioned the problem that we do not expedite change quickly enough in this area. I feel the frustration the same as many Members of this House. However many of those frustrations, especially in recent years, have been caused by industrial relations problems which are outside the remit of the Department of Health and Children or the HSE. I ask the Senators who have expertise in mental health and bringing best practice to fruition to give as much attention to industrial relations problems that delay the implementation of necessary changes in the health services as they give to the lack of facilities. The provision of facilities for vulnerable people is often delayed by people with vested interests using those people and the strong positions they hold in society to ensure that certain things do not happen. They know these things should happen and that it is best practice that they do, but they delay those changes for their own selfish interests, which are often contrary to the best interests of the patients whom they are there to serve. I say that of all professionals in this area. The patients are the most important people when discussing mental health.

Senator Ryan asked about the escorts. Again, there is an industrial relations problem in this area. Important high level talks are taking place at present between the Department of Justice, Equality and Law Reform, the Health Service Executive, HSE, the Department of Health and Children and the other stakeholders. I do not know if the matter is resolved yet. I hope it will be. This industrial relations problem could again delay things for patients.

I do not have time to discuss every issue raised by Senators. Senator Feeney referred to Sligo. I was delighted to hear that a service has evolved there where cognitive behaviour therapists are assigned to general practitioner units. That is advanced thinking in action. It is desirable that people throughout the country should have direct access to psychological therapies. The gatekeepers, that is, the general practitioners and the psychiatrists, have not always held the view that people should have psychological services but there is now a general recognition that they should. I hope a situation will soon evolve whereby people will be able to get these services of their own accord or be referred directly by a general practitioner. That will mean a huge change in the general medical service.

Obviously, if people pay for their services, they can pay for whatever services they require, but for medical card patients a system will have to evolve whereby patients can be referred by their general practitioner for psychological services. That system is not yet in place but there is a desire that it would happen.

Senator Browne mentioned the National Treatment Purchase Fund and how it can be used for vulnerable people. That is a good idea and I will examine it. However, there are issues involved whereby systems could be abused in order that certain people might earn more money. That is as kindly as I can put it. It would be preferable if proper multidisciplinary teams were in place.

Some speakers mentioned the Criminal Law (Insanity) Act. It is causing certain problems for the Central Mental Hospital at present but we are trying to resolve them. Seven extra beds have now been assigned to the Central Mental Hospital to deal with the problem of people being referred directly from the courts to the hospital.

Senator Norris referred to the recent report by Dr. Dunne on psychological services. I spoke at the seminar on the psychological services. The Government is doing a huge amount to ensure there are more psychology students in our universities and that more psychologists graduate to be employed by the HSE. Unfortunately, it takes some years for people to get through the courses involved.

I have also spoken to the counsellors and encouraged them to do as much as they can to work together to establish standards. Some psychological practitioners have very high standards but, unfortunately, some people have low standards in this area. The objective is to get a via media or middle road whereby we will provide good psychological and counselling services. Counsellors will be regulated properly under the Health and Social Care Professionals Bill. However, they must agree on the issue themselves. We continue to liaise with them.

Senator Ormonde mentioned several matters about which I feel very strongly, as do all Members who spoke in the debate. The words "respect", "empathy" and "dignity" are important when treating people with mental health problems. This is not just a matter for the Department of Health and Children or the Government. All parts of society must deal with this issue. It is ironic that there was never such wealth in our country previously but, parallel with that, there has never been as much depression and unhappiness. That sends a strong message that the opinion makers, our educational system and our sense of values need to be examined closely and challenged.

As a society we do not spend enough time with vulnerable people or listen to people or their problems. There is a definite connection between the excessive consumption of alcohol and depression and suicide. Our society has created great wealth but that wealth, in monetary terms, means nothing if we are not happy people or are unable to look after ourselves. I challenge everybody in society to realise that life is not about money but about how we live as a society. There is a huge sociological task to be done in terms of the discussion about mental health.

I thank the Senators for their valuable contributions to this debate. I look forward to continuing to work with them to ensure that the people for whom we are responsible are provided with the best services.

Sitting suspended at 1.28 p.m. and resumed at 1.30 p.m.