Seanad debates

Tuesday, 23 March 2010

4:00 am

Photo of John MoloneyJohn Moloney (Minister of State, Department of Education and Science; Minister of State, Department of Health and Children; Minister of State, Department of Enterprise, Trade and Employment; Minister of State, Department of Justice, Equality and Law Reform; Laois-Offaly, Fianna Fail)
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): I am glad to have this opportunity to come to the House to speak about mental health and, in particular, the Government reform programme, A Vision for Change. A Vision for Change is a seven to ten year Government reform programme now into its fourth year. Before I continue I hasten to add and suggest that the rate of reform has not been what had been anticipated. I do not intend to use the prepared speech to discuss what has been achieved. While that has some importance, the most important part is what remains to be done. I acknowledge that much needs to be done and I intend to use my time to talk about this.

Upon my appointment some 18 months ago, I made some clear commitments in the area of the reform programme by way of the targets set. I welcome robust debate on this issue and any debate should not only be about what we in the Department are doing. I realise much needs to be done and I welcome debate on the relevant areas.

When the capital programme was announced I set myself a target of visiting all the psychiatric hospitals in the State during the past 18 months and I have visited most of those hospitals to date. While these visits were prearranged, they were in a private capacity, but they were notified to the media and local politicians in an attempt to try to work with the hospital staff, patients and their representatives to progress a development and closure plan. At the end of the round of visits the next part of the plan was to ensure we put a capital programme before Government. The capital programme was approved in this year's budget. It is a €50 million multi-annual programme dependent on the sale of properties. I will outline the properties in question but, more important, I will refer to the capital committed for this year and future years. It is important to note that the capital element is very important. I chose to say we could deliver on the closure of all the hospitals in a three year period. I did this specifically because I believed that to extend the time commitment would reduce the importance of the closures.

I intend working with the Irish Council for Social Housing on this matter. The council has visited me already and we are preparing a joint commitment and presentation which will involve the Minister of State, Deputy Finneran, myself and officials to ensure the management of the capital programme and to provide for the closure of the hospitals. This programme will also involve an element of voluntary housing and I intend to expand on this matter later during questioning.

We must ensure the commitments in A Vision for Change are based on the recovery model and that they refer to the transfer from institutionalised care to community care, which will be the cornerstone of the reform programme.

I made it clear at the beginning of my time in the Department that it was very important to have a directive for mental health as proposed in A Vision for Change. I am very pleased to have made this case to the HSE. The HSE and Professor Drumm have acknowledged this and I am pleased to note that Martin Rogan, the relevant director, is someone with a track record who has come from the psychiatric services and who has practised as a nurse over the years.

I intend to refer of a very important part of the reform programme that I will present on 15 April. Even if there were no difficulty with funding we would have to work within the terms of the available funding. The most important thing I could say in this debate is that even with all the capital support necessary to deliver A Vision for Change unless we deal with the issue of stigma and its eradication, efforts will be of little benefit.

I wish to take some time to elaborate on the national campaign I will introduce on 15 April. I realise difficulties exist in respect of the moratorium and how we can deliver the change and I will address these matters presently.

I make the point that any commitments I have made to date, I have lived up to. I believe somebody has said about me that there is a lot of vision but little change. I hope people will check the record to see if that stacks up, as I do not believe it does. I have lived up to the commitments I made on the capital programme, the director and the transfer from institutional to community care within three years. I am not big-headed enough to believe I will be here for three years, but it is important that each March the Minister, whoever he or she is, as long as the programme is place, confirms what has been achieved in the previous year and, more importantly, what is proposed to be achieved in the following year.

While many issues keep cropping up, I must prioritise. Priority must be given to child and adolescent care. As I have heard quoted by many eminent persons in the service, some 70% of mental health difficulties begin in the child and adolescent years. In that context, I have asked the Government to prioritise funding for early intervention measures. In saying this, great credit is due to the staff involved in the services. It is also important to stress that we are all in this together. It is not a party political move on behalf of anyone. I have heard Mr. Tony Bates, for instance, speak for Headstrong and see what is happening in Ballymun and Galway. I have visited those facilities. I am also pleased to say that last month we visited Roscommon where I was happy to see so many people around the table - representatives of FÁS, the local authority, the VEC and the community and voluntary sector - all promoting the concept of community support on mental health issues. I give full credit to the people involved. I refer, for instance, to the American philanthropist, Mr. Chuck Feeney, who has worked with the Government to provide the necessary funding to deliver the Headstrong programme, Jigsaw. I am pleased to say that last week the Government committed itself to funding the reform programme in Roscommon which forms part of a national campaign.

I do not want to bore Senators by talking about achievements. Clearly, they are only matched by commitments and progress on what remains to be done. I ask Senators to bear with me as I show them that while we are in difficult financial times, progress is being maintained. A total of 55 child and adolescent mental health teams are in place and a further eight are being developed. The number of inpatient beds for children and young people has more than doubled since 2007. It has increased to 30. A further two 20-bed units are under construction in Cork and Galway. I had the pleasure of turning the sod at both facilities. The commitment made in A Vision for Change is that 100 beds will be provided. I appreciate that we are not halfway there, but I ask Senators to realise that we are speaking about work in progress and delivering on this commitment before the end of the programme.

The Mental Health Commission's code of practice relating to the admission of children to adult units in approved centres was amended to require that from 1 July 2009 no child under the age of 16 years be admitted to an adult psychiatric unit, that no child under 17 years be so admitted from 1 December 2010 and no child under 18 years be so admitted from 2011. This, together with the provision of additional beds, will substantially reduce the number of admissions to adult facilities. To my mind, that is progress, but it is not enough.

The first annual report on child and adolescent mental health services was launched in October 2009. It provides comprehensive data on the level of activity in the service, as well as important information on the young people presenting and how the nature of their condition changes with age.

Some 19 additional beds in the Central Mental Hospital and six places in a step-down residence in west Dublin have been provided, as well as the in-reach service to prisons, including clinics at Cloverhill, Mountjoy, Wheatfield and Arbour Hill Prisons. Further details are contained in my statement.

The Central Mental Hospital recently won an award for best hospital project in the Irish Healthcare Awards 2009 and the An Duais Mhór trophy for its prison in-reach and court liaison service. The service is a fine example of collaborative working, involving gardaí, District Court judges and staff of the Irish Prison Service and the forensic mental health service.

It is worth noting also that shorter episodes of inpatient care have been achieved and that 50% of discharges occur within two weeks of admission. There are also fewer involuntary admissions.

Executive clinical directors have been appointed to lead reform in catchment areas serving populations of 350,000 to 400,000. I see the role of director as working with clinical directors to establish what can be achieved in A Vision for Change and, more importantly, if there are barriers to progress and, if so, to have them removed. The appointment of Mr. Martin Rogan as national lead within the HSE is an important step in implementing A Vision for Change.

I do not intend to read from my prepared script on the National Service Users Executive. The executive is part and parcel of the reform programme and involved in every aspect of implementation of A Vision for Change. I particularly thank those who were in the House last November when we debated the issue of ECT. Obviously, I thank Senators on the Government side from where I expected to receive support, but I particularly thank Senators on the other side for, as it were, stepping aside from the politics of the issue and postponing the decision until such time as we presented information to the House on the matter. I recognise we have had an opportunity to debate the pros and cons of ECT treatment in the House in the past few weeks. It is up to us to keep faith with our commitment to bring forward the heads of a Bill not later than June.

On the commitments given on the capital programme, I have always believed that, even though there has been significant progress made, the public is aware of the old grey Victorian buildings. Having had the opportunity to visit so many of them, I realise that altogether there are approximately 1,200 patients who could live outside. Clearly, there were no press statements or political announcements on the capital programme, nor do I intend to make any. This is something that should be done properly by way of the HSE making the announcements. I am pleased to say, on behalf of everyone here, that the capital programme is now under way, involving the first tranche of the €50 million. On the long-standing commitment to provide a new acute psychiatric unit in Letterkenny, this week the contractor was on site as part of a capital programme worth in the region of €6 million which will be delivered within 15 months. The capital programme also includes St. Loman's Hospital, Mullingar. I am trying to deal with the highlights in the report of the inspector each year which covers conditions not only for patients but also for the staff who work in the hospital. I understand work will begin on the new 50-bed unit adjacent to St. Mary's Hospital, Mulligar at the end of next month. It will replace St. Brigid's Ward and St. Marie Goretti Ward. On the long-standing commitment to provide the new psychiatric unit at Beaumont Hospital, I expect the Department and the HSE to seek planning permission by the end of July. There is a sum of €25 million to be provided in Senator Prendergast's area - Clonmel. I am not shouting about these developments. They are part of an ongoing process.

I was in Grangegorman sometime ago and I am pleased to be able to say that within eight to 12 weeks the enabling works will begin. The objective must be to meet the commitment given to provide the new 66-bed unit.

I ask Senators to allow me a minute or two to deal with the forthcoming stigma campaign. There is in place the capital programme, as well as the director. There is the commitment to close hospitals within three years, to ensure we make the best use of primary care centres to house community mental health teams, to meet the specific targets set in respect of child and adolescent mental health and, most importantly, that the Minister involved should be present at the launch of the report each March at Farmleigh House.

Having met the various groups involved over the past 18 months, I know the main issue is how we deal with the stigma attached to mental health illness. Senator Frances Fitzgerald and Deputy Chris Andrews invited Mr. Kjell Magne Bondevik to address the cross-party Oireachtas group on mental health. I have had the pleasure of hearing him on many other occasions.

Since I took up office I have always believed the real trick will be to ensure the issue of mental health illness is tackled in the same fashion as physical ill health. My intention is to drive a reform programme on the capital side with the closure of older hospitals and make people aware of the need to protect their mental well-being.

In the past I have referred to the time when my doctor in the Mater referred me to a psychologist in late 2007 after treatment for a nerve pain in my face which was related to stress. I am happy to say I attended five sessions and that it helped me recover from that bout. I hope this will encourage people to talk up the issue of recovery models as envisaged in A Vision for Change.

I invited people and organisations involved in mental health well-being to help drive a national campaign, Sea Change, the national mental health stigma reduction partnership. At long last, it will be launched on April 15 in the Mansion House. I thank Mr. John Saunders, who headed the effort, and all those who worked hard to bring it together. Anyone I approached to assist, be they in politics, the arts or sports, became involved in the campaign. It will bring together all the groups involved.

Going around the country, I met so many different groups and people who wanted to raise awareness about mental health well-being. Often, however, I heard them blame politicians for not being more pro-active in suicide reduction. The launch of Sea Change will be an opportunity for them to row in behind us. While I do not want to go much into the details of the campaign now, the reach-out will be to local media. National campaigns are beneficial in themselves but local media involvement is also required. Local sports stars, politicians and artists will participate in weekly magazine programmes on local radio to say it is no big issue if one needs mental health support. We have also approached people with national profiles to help launch the campaign and they have all been willing to assist.

When one in four people will suffer some mental health problem, it is important facilities are put at their disposal and that coming out about it should not affect their employment, promotional or home-owning prospects. Many are frightened of the idea of mental ill health. The campaign will also explain the different levels of mental illness and be committed to the recovery model. The various diagnostic titles such as psychosis, schizophrenia, bipolar disorder and depression are often seen as lifetime labels. This campaign will be targeted at ensuring such lifetime labels around these illnesses are reduced and eventually dismissed to allow people every available route to recovery.

The commitments made in A Vision for Change will be delivered in the existing timeframe. While I accept not all Members will sing off the same hymn sheet, we all want to see reform in the provision of mental health services. It is important, therefore, targets are set every year and their success measured. The only way to ensure continuing reform in the mental health services is to have specific funding ear-marked in the mental health programme. A proper presentation on this will have to be delivered; it cannot be shoddy. A Vision for Change can be delivered upon as it was compiled by those who use the services. It is important the supports it promises are delivered across the board in psychiatric care. It is up to us to deliver on this reform roadmap.

Photo of Frances FitzgeraldFrances Fitzgerald (Fine Gael)
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I welcome the Minister of State, Deputy Moloney.

The launch of the Sea Change campaign on 15 April is critical and I assure him of 110% support from this side of the House. It is an initiative I welcome. The issue of a stigma around mental health issues is enormous and blights people's lives, self-esteem, employment prospects and their families every day. It is critical we begin to deal with it nationally, as well as helping people deal with it personally. I hope it will be a multifaceted campaign and will continue for as long as it is needed.

The stigma surrounding cancer only began to lift in recent years. There was a time when women were too frightened to speak about breast cancer. Only in retrospect can we see how ridiculous that was. Only when we tackle the stigma around mental health issues will people get more effective help earlier. Many mental health difficulties arise in adolescence. It is critical those it affects get help in time and the services they need. When people are too afraid to speak about it in school or to their employer because of the stigma associated with it, it only leads to further difficulties.

I welcome the Minister's personal commitment to this area. He spoke of his own experience which will be helpful for many people. I refer to the 400 patients in care in old psychiatric hospitals who should not be there. It is interesting to see the report from the Department of Health and Children. There are 4,700 people in old hospitals. The Department report refers to 400 people who should not be there. I welcome the commitment to capital funding.

The Minister of State should clarify what will happen if the sales of these properties do not go ahead or if the properties have been greatly reduced in value. We know the property market at the moment. What are the implications for mental health funding? Is there a guarantee from the Government for the €50 million over three years or is that dependent on the sale of property? If dependent on sales this year, it could be very problematic even if new facilities can be built at a cheaper rate. The Minister of State can clarify the funding mechanism with regard to the sale of these lands . If the lands were being sold in the Celtic tiger era, one would be optimistic about the money they would generate which could then be ring-fenced. It is important the money is ring-fenced. What will happen if there are no sales this year? What will happen to the sum of €50 million for this year, next year and the year after? I would like as much information as possible on that point.

There have been difficulties with the transparency of mental health funding. I am aware of the economic downturn. Perhaps the Minister of State will comment on the fact that it seems the proportion of spending on mental health is now 5.4%, far below the Government's commitment to 8.24%. I ask the Minister of State to address the implications of this and explain how it happened. What is included in that figure of 5.4%? I have a number of questions on the money that will be spent in A Vision for Change. It is quite difficult to get this information in meetings of the Joint Committee on Health and Children. I have no doubt the heart of the Minister of State is in the right place and he has good intentions but good intentions will not fund our mental health service. Funding questions are critical if we are to see the provisions in A Vision for Change implemented. This programme is far behind but the fact that Mr. Martin Rogan is in place as director and the existence of the service users council are positive developments.

If A Vision for Change is to become reality, there will be community mental health teams and rehab and recovery teams in place. To close outdated facilities, proper community facilities must be in place. Is the HSE committed to putting more teams in place this year, for both adults and children? What is the number of teams? For example,the target for the plan for child and adolescent mental health teams was 55. Is that 55 for 2010 and does this represent the same 55 talked about for 2009? In other words, is the sum 55 teams in total? I am assuming the figure is not 110 in total but that may be the case. There have been a number of announcements.

I refer to waiting lists for child and adolescent services. A number of the teams will only accept acute emergencies where patients are psychotic or suicidal. Many parents are unable to go to local mental health teams and be assured of an assessment service within two years. Waiting lists vary greatly throughout the country. Many parents cannot get access to the service unless one is in a total crisis. Are figures available for waiting lists throughout the country? Is the Minister of State gathering these and is there an intention to deal with them in a particular timeframe?

I welcome the commitment by the Minister of State that children will not be admitted to adult inpatient units. That will cease completely by 2011. This shows the importance of having targets and monitoring what is happening. We can monitor this over the next three years.

The HSE had targets for a number of areas regarding mental health last year, including reducing the proportion of admissions that are readmissions and reducing the involuntary admission rates. These targets are not met, perhaps in part because of the lack of a comprehensive community-based mental health service. This raises the question of getting the community services in place as quickly as possible.

What is the relationship between the Minister of State, the Department and the HSE? The Minister of State sets targets and talks about what he wants to achieve. Then I see the HSE trying to implement the targets but not achieving them. The policy of the Minister of State is not being implemented. What is the mechanism to ensure targets set are met? What are the concrete plans to achieve these targets? When we have this information available regularly, the credibility of the Minister of State will be much greater. There is a gap at the moment and it is quite confusing when we try to get clear answers on the issue of funding in meetings of the Joint Committee on Health and Children. It is very difficult to get clear answers on what funding is ring-fenced and what money is allocated to the mental health budget. The proportion has decreased and this speaks for itself. The financial information given by the HSE, especially for the service plan for this year, shows the budget for mental health services is €240 million lower than the 2010 Revised Estimates. Where has the €240 million gone? Has this been allocated to the general health budget? It is a matter of transparency and trying to see what has been spent in this area. I have laboured the point but it is important in terms of the credibility of the programme. We must have clarity on the funding, the amounts, the percentages and the targets set for proportions of the mental health budget in 2010 and 2011.

It is important to highlight that mental health is not a matter for one Department and that it concerns other Departments. The Minister of State provided the example of the housing section in the Department of the Environment, Heritage and Local Government and its critical role in this area. It would be helpful to find out how other Departments implement A Vision for Change. In the field of equality, for example, we asked every Department to quality proof its policies. It would be useful to ask Departments to provide a response to A Vision for Change and the aspects of it that involve them. We should ask for reports from them. The Minister of State with responsibility for mental health should be a super junior position because so many Departments are involved. The housing section of the Department of the Environment, Heritage and Local Government has a part to play, as does the Department for Social and Family Affairs and, particularly, the Department of Enterprise, Trade and Employment. I would like to hear from the latter Department about the links it can make to the Department of Health and Children. The stigma and the nature of some mental illnesses, where people move in and out of the workforce, means there is a need for particular support and understanding from employers or social welfare officials dealing with those coping with mental illness. Much work remains to be done with these Departments and we need a multi-departmental approach to the implementation of A Vision for Change.

Some organisations, such as Amnesty International, are very keen to see if we can introduce legislation to underpin A Vision for Change. Service provision is always a difficulty because of the limits of what the Government can promise but it is an interesting area to consider. I wish the Minister of State well with the new initiatives and I recognise that some progress has been made. However, A Vision for Change is far behind schedule and there have been serious problems in respect of funding, some of which has been siphoned off to the general health budget. I would like greater clarity in the future on the current funding mechanisms, the proportion being spent on mental health and the funding generally the Minister of State envisages over the next three years.

Photo of Maria CorriganMaria Corrigan (Fianna Fail)
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I welcome the Minister of State. Along with Senator Fitzgerald, I found his contribution to be very interesting and thought-provoking, especially when he deviated from the script. It reflected the personal commitment, enthusiasm, dedication and energy he has brought to this portfolio.

Members have sought this debate for a long time. All of us have raised it on the Order of Business at one stage or another because of the concern that this can sometimes be an area that is neglected. However, it is important to start with a message of positivity. It is important to say that we can intervene effectively for people experiencing mental health difficulties. We can prevent mental health difficulties arising and we can promote and enhance our mental well-being. We can be ambitious in terms of people with mental health difficulties being facilitated to make a full contribution to our society. That is the tone in which this debate takes place and it reflects the contributions all of us have made previously, whether in other debates or on the Order of Business.

The Minister of State referred to A Vision for Change, which is undoubtedly an outstanding blueprint for the development of state of the art mental health services that will ensure we provide access for all people. It is a plan of which any country would be proud. As the Minister of State said, one of its undoubted strengths is that it is the product of a combined effort on the part of patients, family, staff and services and that it is supported and has the confidence of all concerned.

Achievements have been made, and it is important to acknowledge those achievements. The Minister of State referred to them but said he did not want today to be all about those achievements because many challenges lie ahead. However, I would like to acknowledge some of the achievements. The establishment of the Office for Disability and Mental Health was a particularly important step. The developments that have taken place regarding the increase in the number of beds available for child and adolescents are important, as is the commitment given that we will reach a stage where children under the ages of 18 will not be admitted to mental health wards. The naming of Mr. Martin Rogan as the lead person for mental health is another important step. It is important on a day like today to take the time to acknowledge that. I would like to take up the Minister of State's invitation to discuss also the challenges involved, of which there are many. I will try not to repeat those already outlined by Senator Fitzgerald because we are all under pressure in terms of time.

The first challenge we must discuss is the confidence people have in the implementation of A Vision for Change. As a result of its slow start, many people's confidence in it was somewhat shaken. That has some of its origins in the role played by the Health Service Executive in particular and its engagement in it. I do not want to knock the Health Service Executive. I am well aware there are many staff members in front-line positions within the HSE who work very hard to deliver quality mental health services. However, serious concerns have been expressed over the years about what happened to all the additional money allocated to mental health services. We all recall when the extra €25 million that was indicated would be needed for the implementation of A Vision for Change was allocated in the budget but it could not be traced or found to have been spent in the mental health areas. Indeed it was one of the reasons no additional funding was provided in the budget for mental health services in one year because there had not been a demonstration that money had been spent within that area.

I welcome the steps the Minister of State has taken to bring the implementation of A Vision for Change back on track. I welcome the plan outlined on 1 March in his Department and at the Farmleigh event. It was clear there was a renewed confidence and vigour among everyone attending and it gave them great heart but given that questioning, I ask the Minister of State if there is a role for the Oireachtas to play in the overseeing of the implementation of A Vision for Change. Is there a need for a specific Oireachtas joint committee to be established to which the HSE would have to report regarding the implementation of A Vision for Change? If such a step were to be taken, it would renew confidence and would also send out a positive message that mental health is a priority for the Oireachtas. Not a week goes by in the Seanad or the Dáil that Members do not advocate for mental health but somehow, and especially in this economic recession, mental health is not covered in the national media and can be seen, therefore, as something that is not necessarily the priority we all know it to be. Giving the Oireachtas a role in the implementation would be one way forward.

I welcome the capital project the Minister of State outlined on the previous occasion but I want to address the revenue provision that will be made for ongoing service development. I welcome the commitment and the identification of early intervention and adolescent services. We are aware that the earlier we intervene, the more positive the prognosis. We see that in projects such as DETECT that have been run by Dr. Eadbhard O'Callaghan and his team in St. John of God Hospital. We are aware also that other projects such as Headstrong, which is run by Tony Bates, intervene with adolescents at an early age and remove the stigma around the issue for adolescents by making it a natural part of development. If a teenager is not feeling well and he or she wants to call in to Headstrong, he or she can do so. There is no big deal about it. That is an important message and I welcome the fact that the Minister of State is prioritising those services.

I ask the Minister of State not to forget about older people with mental health issues, which is a major challenge facing us. Issues will arise for people in nursing homes with age related disorders in that initially they will qualify under the fair deal scheme but when they require that extra support in a dedicated mental health facility, even within the nursing home, they will no longer qualify. We are aware that people are living longer and with age related disorders we are seeing more challenging needs that require a greater degree of support. I ask the Minister of State to provide for those.

I echo the point raised by Senator Fitzgerald. I, too, would like to know about the apparent difference between the HSE service plan and the Revised Estimates, which is approximately €240 million.

I ask the Minister of State also if it would it be possible for us to set in stone a proportion of the health budget to be spent on mental health, whether it be 8% or 9%. Could that money be ring-fenced in some way to ensure it is not appropriate for that money to be diverted to any other part of the health service? Investing in mental health is a positive investment for our communities.

Regarding A Vision for Change, what measures will be taken to provide mental health services for people with intellectual disabilities? Also, has a decision been made yet regarding the location of the new Central Mental Hospital? It would be an awful shame, in the context of the Sea Change campaign being run by the Minister of State, if the Central Mental Hospital were to be located on the grounds of a prison. I believe this would be counterproductive in terms of what we are trying to achieve.

While funding is an important part of A Vision for Change, it is not all that is necessary. The Minister of State identified some of the other challenges in terms of the moratorium and employees being required to change jobs, train and upskill. Legislative issues also arise. Some changes recently introduced by way of legislation are positive. However, the mental capacity legislation must be brought before us as quickly as possible. This legislation could have a profound impact on so many different sectors of society. It is of the utmost importance that we are given the maximum possible time to consider and debate it as its implications will be felt for a long time.

I welcome the progress made in the area of suicide. The training programmes, such as Assist, run by the National Office for Suicide Prevention, have been worthwhile. Part of A Vision for Change focuses on prevention and early intervention and enhancing our own psychological well-being. I put it to the Minister of State that as a first step in this regard we need to link with schools' SPHE programme. If we want to address stigmatisation, much of which arises from a lack of information and awareness, we must ensure children are at an early stage given a positive understanding of the challenges in this regard and are given, upon leaving school, a proper toolbox in terms of coping and tolerance skills. Again, if we want to pursue early intervention, a key element will be ensuring there is information and awareness in terms of mental health challenges and the help available. When we undertake projects, such as that outlined by the Minister of State, it is crucial, if we can encourage people to talk about mental health issues and to come forward regarding mental health issues, that we have in place a response system to assist people who come forward. That is the role that community mental health teams must play.

On deinstitutionalisation, the plan to close institutions and move people into communities is important. However, I have concerns in regard to community housing. I was delighted to hear the Minister of State speak about voluntary housing. I would like to see us embrace a framework of supported living. There is a danger of community houses becoming mini-institutions. Where community housing is established, what will be the position in this regard in terms of the inspectorate given they will no longer come within the remit of the inspectorate of the mental hospital? An issue of concern, even in terms of adults with intellectual disability, is that there is in place an inspectorate in this area.

I thank the Minister of State and wish him well.

Photo of Phil PrendergastPhil Prendergast (Labour)
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I thank the Minister of State for coming to the House. I have a somewhat different story for him and would like to make a few observations. It is my belief that A Vision for Changeis being abused by the Health Service Executive. It is supposed to be the blueprint for the future of our mental health services but it is being used as a type of propaganda tool.

My experience to date in Tipperary is that the HSE south has no intention of following A Vision for Change, a conclusion I have drawn from the untruths it tells the Irish public, more detail of which I can provide for the Minister of State. The Minister for Health and Children, Deputy Harney, and the Minister of State, Deputy Moloney, are not taking responsibility for this issue and are allowing themselves to be treated as HSE salespersons. It has become obvious at this stage, in the context of the Tipperary mental health services, that the Minister has taken on the role of selling HSE ideas to the public.

I would like to deal with the decision to close the 49 acute bed unit on the general hospital campus in south Tipperary as announced on 12 January. I would like to know the Minister of State's input into that decision-making process, which appears to be non-existent given his detailing in regard to how the decision was arrived at. I would like to know what input the Minister of State had in that decision and the status quo in this regard.

I met and received a briefing from Amnesty Ireland who has a number of wide ranging concerns in regard to A Vision for Change, some of which have been raised by previous speakers and which I will not repeat. I would like to know how many community health teams are in place as there appears to be a discrepancy between the number given by the Minister of State and the actual number in place. Perhaps the Minister of State will clarify the position in that regard and in regard to how many children's teams are in place. Children continue to be admitted to acute psychiatric adult wards and there are waiting lists in almost every HSE area of children awaiting assessment by psychologists and psychiatrists. The staffing levels in mental health services continue to be 50% below what is required. These figures have been supplied by Amnesty Ireland.

One fifth of what is envisaged in A Vision for Change has a cross-departmental element to it. This creates difficulty because co-ordination of mental health issues across the Departments of Health and Children and Justice, Equality and Law Reform and the SPCs, in terms of housing and social policy and how people are rehoused and taken care of in the community, is a big issue.

On the decision to close the acute unit in south Tipperary, an issue we have previously discussed with the Minister of State, the option appraisal document is three and a half pages long and was presented to the hospital executive at South Tipperary General Hospital as being the process by which this decision was arrived at. The document, entitled Proposal for the future of St. Michael's Unit Clonmel, states:

This paper sets out some of the background of St. Michael's Unit and puts forward the number of different options with regards to the future. [Background] St. Michael's Unit is a single-storey acute adult inpatient facility built in (?) and has 49 beds across two separate wards. There is a small high dependency unit (more detail ? seclusion room suite). It has an ECT suite and (? Fulfilling the national standards). Attached to the ward area a variety of offices to accommodate nursing and medical staff. Outpatient clinics are held here and in more recent years it has functioned effectively as an emergency drop-in facility (expand detail). A variety of Mental Health Commission reports have highlighted many of the shortcomings of this facility both in terms of physical structure, access to outside space and to meaningful daytime occupational and leisure facilities. It has been felt that these do not meet the requirements of a modern inpatient psychiatric facility. Additionally these reports have highlighted or suggested outdated standards of care or practice, possibly related to the association, with an older long stay institution next door. [He refers to St. Luke's which we all agree must close.] There have been issues with inflexible rostering and a lack of continuity of care. There appears to have developed a culture of risk averseness and in common with many other units significant problems with a population of people with co-morbid psychiatric and alcohol and polysubstance misuse problems. There have been significant attempts to address these problems including a St. Michael's Unit Group formed some years ago to look at the integration of two wards and setting standards for the unit. The development of an out of hour's service whose intention was to decrease admissions and more recently a Bed Management Group. Despite this and many other efforts the unit continues to be occupied at above 100% of its capacity and on leave beds are used to accommodate emergency admissions.

St. Michael's Unit for 40 years has admitted patients from the North Tipperary Sector and this amounts to approximately 40% of its bed capacity. Attempts have been made in the past to reprovide for the inpatient needs for North Tipperary patients but without success.

[Limerick, which is supposed to take these patients, cannot accommodate them.]

There are now significant challenges ahead in meeting the needs of the local population for their inpatient and community care including the necessary resources in line with Vision for Change guidelines and external imperatives such as the European Working Time Directive (EWTD) for Junior Doctors which needs to be implemented forthwith.

He then names two personnel, whom I will not name because that would not be correct before stating:

...please add in additional significant headline difficulties. You may want to also add in some strengths that say something like, "despite these difficulties staff have managed to carry on working in these very difficult circumstances with a high degree of commitment and effort").

Option One

Do nothing.

This is probably not an option as allowing the current state of affairs to continue would be unfair and would continue to ignore the inpatient care needs of the local population in the current physical environment.

Option Two

Redesign and refurbishment of the wards on the existing site including creation of an appropriate locked ward facility with appropriate seclusion facilities.

This would probably entail a reduction in the number of beds and reproviding for North Tipperary patients elsewhere. Given the physical nature of the site this is likely to be expensive in terms of capital costs and would not necessarily solve the practice issues referred to above. Equally redeveloping this site would mean there were too many acute inpatient beds for the population of the expanded directorate of Carlow/Kilkenny/South Tipperary (220,000 - 88,000 for South Tipperary). A bid for funding for such capital development would be in competition with other community capital development, which would be more in line with the modernising of mental health services as set out in the Vision for Change strategy.

Option Three

A new mental health facility build either on new site or current site. This option could include provision for North Tipperary patients or not.

While this may be attractive politically it would still suffer from the same problems as the previous option in that it would be competing for capital funding with community-based facilities and services and out of keeping with the total number of acute beds needed for expanded directorate catchment area for Carlow/Kilkenny/South Tipperary.

Option Four

Closure of St. Michael's Unit at end of 2010/first quarter of 2011.

The essence of this proposal is that robust alternatives to admission were implemented in the community in South Tipperary prior to its closure. North Tipperary patients would have to be accommodated within their own expanded directorate catchment area. Admissions for South Tipperary patients would need to be approximately halved and be accommodated in the Department of Psychiatry wards in St. Luke's Hospital, Kilkenny.

The advantages of the reprovision of inpatient care needs for South Tipperary patients with the closure of St. Michael's would be:

1. Release of resources to fund more modern community-focused services for South Tipperary, North Tipperary and Carlow/Kilkenny.

2. A provision of a higher standard of physical inpatient environment in Kilkenny.

3. A removal of the requirement to implement EWTD for Junior Doctors in South Tipperary.

4. Increase capacity of mental health staff to concentrate on community service provision, most notably Consultant Psychiatrists who would not be required to provide inpatient care for their patients while accommodated in Kilkenny, thereby releasing them to focus on community service development and community provision (anything else).


1. Local/political concern about change in provision of services.

2. Resistance from staff groups.

3. Travel to and from South Tipperary to Kilkenny for patients and their friends/relatives.

4. Difficulties in implementing changes in mindset/work practices e.g. change in consultants' job remits.

5. Significant cost of funding adequate community resources to implement this option fully, safely and effectively.

6. Potential for increased numbers of incidents in community.

7. Concerns and possible resistance from other chief stakeholders, e.g. Gardaí in cases of for instance, involuntary admissions, assisted admissions etc.

8. Significant difficulties for Limerick or Mid-West expanded catchment area to reprovide for North Tipperary inpatient needs, (any others?)

This is the option appraisal document which led to the announcement of the closure of 49 acute beds in south Tipperary and I cannot believe the Minister of State signed off on this because nowhere in the document is what should be in an option appraisal document. I have an example of what should be in such a document and it provides for consultation. There was no consultation with the nursing staff, psychiatrists, the staff running the hospital or the patients and this decision was announced on 12 January.

Dr. Kelly continues:

In order for this option to be feasible a number of essential requirements would need to be implemented:

1. Creation of a project team to oversee reprovision programme - January 2010. This can be achieved within existing resources and consist of essentially an expansion of the project team overseeing the closure of St. Luke's Hospital.

2. Effective engagement and communication strategy for all key stakeholders both internal and external to the organisation within existing resources.

3. Development of home based treatment services comprising of 0.5 WTE consultant, 1WTENCHD, 1 CNS, 10-12 WTECMHNs, 0.5 WTE psychologists, 1 WTE social worker, 1 WTE O.T., 3-4 WTE healthcare workers, 1 WTE admin support (see appendix for model).

4. Team base for home treatment team? St. Michael's Unit or exiting community facility.

5. Provision of training programme.

6. Crisis house in community.

7. (any other central requirements?)

This document is dated 6 January 2010.

The Minister of State referred to the construction of the new unit in Letterkenny, the construction of a community nursing unit in Clonmel and the closure of St. Luke's Hospital but he did not mention the closure of St. Michael's unit on the general hospital campus. Perhaps he will clarify the decision. If the appraisal document I read into the record constitutes a decision-making process that does not involve a member of staff working in the facility or providing services, will he clarify how the HSE is doing its business and how the people of south Tipperary will be treated?

Photo of Niall Ó BrolcháinNiall Ó Brolcháin (Green Party)
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I wish to share time with Senator Boyle.

I welcome the Minister of State. I am a great fan of A Vision for Change. Change takes time and it has to happen on a planned and clear basis. The keyword is implementation and this is what we need to focus on. It is unfortunate we are experiencing a recession because recessions tend to lead to a greater need for mental health services with depression, in particular, becoming more pronounced. However, resources are also more difficult to provide. Nevertheless, we must do the best we can in this regard.

The move from the Victorian model to a community-based model will be excellent. The strategy is the way forward and implementation is the key issue. The principles underpinning it must be considered and it deals primarily with putting in place secondary care community-based teams. They comprise psychiatrists, psychiatric nurses, clinical psychologists, social workers and occupational therapists while art, music and drama therapy will also be provided. The regionality of services being provided currently is a problem in that some areas have much stronger services than others. Should we consider rolling out the teams as best practice pilot models or should they be rolled out on the basis of equal provision throughout the country? The model which provides that some areas do slightly better than others is not necessarily the best way forward. What is the Minister of State's view on that?

The issue of primary health care is crucial and the Minister of State speaks a great deal about it. The idea that when somebody goes to a doctor, he or she is immediately referred to a secondary team when there is a mental health issue is unacceptable. As much as possible must be done at primary care level before moving to the secondary level. I realise that "co-location" is a dirty word but it is suggested primary health centres could be co-located with secondary health centres in some cases. That is probably a good model.

My final point relates to cures for mental health problems. There is a dependency culture in mental health treatment in that it is very much a drug based system. The principle of shying away from drugs as much as possible and not using them where it is possible to do so is a good one. We should be seeking to cure mental illness, not simply treat it at a palliative level. It is important to proceed in that way.

The moratorium on the recruitment of staff must be examined. This is an extremely important issue which could have a profound impact on our society.

Photo of Dan BoyleDan Boyle (Green Party)
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The personal commitment of the Minister of State to these issues is recognised by all in the House. The document, A Vision for Change, is acknowledged as progressive and the frustration is due to the delay in implementing it fully. However, the Minister's renewed commitment and the support he is receiving from the Cabinet must be acknowledged. My colleague, Senator Ó Brolcháin, has pointed to the difficulty with the staffing moratorium. As mental health services are more human resource dependent than other areas of the health service, the Minister of State needs every support in dealing with the matter.

I take this opportunity to reinforce that support. The Green Party in this House has placed particular emphasis on mental health. While I thank the Minister of State for organising the recent seminars, I urge him to accept that there is a necessity to make progress on section 59(b) of the Mental Health Act and the concept of coercive treatment for people who do not have the capacity to give informed consent to that treatment. The support he has given to the process of examining this issue should be seen in the context of the overall review of the Mental Health Act and the document, A Vision for Change, which is patient-centred. I hope the House collectively, through the office of the Minister of State, will see a degree of legislative change that will make this area less uncertain and less of a lottery for those who find themselves in the position where they are given treatment which they might not choose to have. My party and I will be happy if that is one of the results of the review.

In general, the Minister of State deserves to be commended for his overall approach. There is renewed confidence that the principle behind A Vision for Change can be achieved, when in recent years it had appeared that the policy document might be veering towards a longer timeframe.

Photo of Terry LeydenTerry Leyden (Fianna Fail)
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): There is a vote in the Lower House. We will suspend the sitting for 15 minutes to allow the Minister of State to vote.

Sitting suspended at 6.15 p.m. and resumed at 6.30 p.m.

Photo of Rónán MullenRónán Mullen (Independent)
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Cuirim fáilte roimh an Aire Stáit. Tréaslaím leis as ucht a chuid dea-oibre. Déanaim comhbhrón leis nach ball den Rialtas anocht é, ach ní fada go dtarlóidh sé sin.

When A Vision for Change was published in January 2006 it was greeted with near-universal approval. No one doubted that mental health services badly needed a substantial overhaul and A Vision for Change was seen as containing a credible blueprint for that to happen by 2016. Since its publication the credibility of the proposed mental health services blueprint has remained a constant. What has changed, unfortunately, is the optimism which greeted its publication. Scepticism as to the implementation of A Vision for Change is largely down to a lack of political will and, in particular, a failure to commit Government finances to the project means that many of its proposals and recommendations remain in limbo. The Government should publically and unequivocally commit to implementing A Vision for Change fully no later than 2016, the original due date. Ease of access was to be a hallmark of a system where the involvement of service users, their families and carers would be encouraged and facilitated as regards the development of services and their delivery. The establishment of highly professional community mental health teams to offer multidisciplinary home-based and outreach care would signal a much needed shift away from the old "battery hen" paradigm of mental health services. The new model would see formal links between mental health services, primary care services and voluntary groups. It would operate along updated geo-demographic trends and within catchment areas of between 250,000 and 400,000. To make room for these changes A Vision for Change recommended the closure of the existing mental hospitals with a view to selling off these capital assets to fund the implementation of the recommendations.

It sounded fantastic, but bureaucracy and lethargy have stymied momentum. Three successive reports in 2007, 2008 and 2009 by the independent monitoring group established to monitor progress in implementing A Vision for Change, criticised the HSE for its delay in implementing key recommendations of the document. The first report took issue with "the lack of a systematic approach to implementation and the lack of clarity in responsibility for implementation in the HSE". The lack of real leadership and a comprehensive implementation plan was noted in all three reports. Though the 2009 report recognised that progress was being made with regard to the provision of child and adolescent services, and also engagement with service users and mental health information systems, it warned "that the recommendations of A Vision for Changecannot be implemented effectively without a National Mental Health Service Directorate". It said the absence of a dedicated leader at senior, national level had impeded progress in the implementation of A Vision for Change and might be contributing to continuing poor facilities and standards of care in some areas and an inconsistent approach to embedding the recovery ethos in services. Two of the key tenets of A Vision for Change have not yet been properly addressed: catchment areas have not yet been put in place, while the resourcing of community mental health teams has not been sufficiently prioritised.

What adds to the disappointment is the insistence on behalf of the HSE that they have in fact released a comprehensive implementation plan. This document is however aspirational in tone and largely uncosted, ambiguous and lacking in a rigorously defined timescale. Indeed, Dr. Siobhán Barry, co-author of a 2009 report by the College of Psychiatry of Ireland which encompassed issues relevant to mental health services, has claimed that at "the current rate of staff recruitment it will take 40 years to implement" A Vision for Change. Her report, entitled A Gloomy View,found that 53% of the services surveyed across the HSE had consistently low levels of recruitment of the promised multidisciplinary team members, with only 16% receiving the resources which they had been promised. It is not as if this shortfall in resources and commitment was unforeseen. In welcoming A Vision for Change upon its publication the Irish college of psychiatrists added the caveat: "We would be concerned that the necessary funding to drive the recommendations will not be made available over the seven years." This was prescient. It pointed out that mental health services in this country have historically suffered from "an acute lack of funding". The college further highlighted that even if all went according to plan the percentage of health monies allocated to mental health would rise from 6.8% to 8.24% - still a considerable distance off the 12% to 14% it recommends. The Department of Health and Children has admitted that while from 2006-09 the HSE was provided with €51.2 million to implement A Vision for Change, €24 million of this was used to meet "overriding obligations of the HSE to live within its approved allocation".

In 2009 the Centre for Ageing Research and Development in Ireland produced a report on the progress of A Vision for Change. It acknowledged the Minister of State's total commitment to the project, as I do here. However, the centre highlighted several areas where implementation was severely behind schedule: the selling off of old psychiatric hospitals to raise the €796 million needed for the new project; the appointment of a director for mental health services in the HSE; and the establishment of community mental health teams to specialise in different areas such as adult mental health, child and adolescent services, the psychiatry of old age and intellectual disability.

I am not suggesting that absolutely nothing has been done to implement A Vision for Change. In 2006 there were 47 community, child and adolescent mental health teams. By January 2009 this had increased to 50 teams while now there are roughly 60. All told, that is a 30% increase since 2006 and credit is due for that. Furthermore, since 2006 at least 18 adult community mental health teams have been created. Earlier this month the Minister of State announced that a total of 14 Victorian-era psychiatric hospitals were to be closed with a total of 1,200 patients to be transferred to more modern community-based facilities within three years. Some of these antiquated facilities were at various stages described as "inhuman" and "deplorable". At the announcement the Minister of State pointed out that there had been a doubling in the number of child and adolescent beds to 30, along with shorter episodes of inpatient care.

However, it would be delusional to believe the response by the HSE to A Vision for Change, thus far, has been anything other than piecemeal. The reality is that implementation is behind schedule, still lacking a truly comprehensive plan and relying on the sale of property to avoid the worst of the property collapse so as to be an adequate source of funding. The final key recommendation of A Vision for Change was that it "should be accepted and implemented as a complete plan". To date that has not happened. What is required is a renewed resolve on the part of the Government and the HSE in particular to honour this document. This resolve must be public and must be framed by a genuine commitment. Therefore I repeat my call on the Government to publicly commit to implementing fully A Vision for Changeby the original due date of 2016.

We are where we are and we all know the situation is very serious economically. I know the Minister of State will be doing as much as he can to bring about the fulfilment of A Vision for Change. However, we also know the test of a civilised society is how it treats its most vulnerable members. I reflect on the plight of those groups of people affected by the lack of modern provision for their needs, despite the fact that some may have concerned loved ones who look out for their interests and are frustrated at the lack of progress on their behalf. There are, however, groups who lack political clout and whose needs have for far too long been unaddressed. There has been a lack of imagination as regards thinking properly about the full dignity of people at all stages of their lives and taking the steps necessary. This is visible more generally in our hospital services as well. Consider the infrastructure of our hospitals and what people have to endure in situations of vulnerability and compare that with the circumstances people with money enjoy when they go to hotels. I often find it remarkable how little hospitality exists in our hospitals despite the good efforts of dedicated staff, primarily because they operate in out-of-date premises, which of course is a central theme here too. It is also a question of ongoing resources.

I had a meeting with the Irish Hospice Foundation this morning to hear about its concerns to try and make hospitals more friendly particularly in end-of-life situations. Relatively small amounts of cash injections by the State could be matched by private donations to try and fund particular projects wherein people would be treated in a more humane manner in hospitals, particularly in end-of-life situations where facilities could be developed for people to talk to a loved one in extremis, or to receive the remains of someone who has just died and so on.

It is true that the times are financially difficult, but we must never forget that this is an indication of the need to prioritise. We shall spend much time, and rightly so, talking about the need for investment in education and research and development. Last week I was among many politicians pointing to the fact that the Irish commitment to research and development has remained constant because we know that is what is needed for the economy to recover. However, we must not forget the heart of our society, which must involve the protection of its most vulnerable members. Mar achoimre beag ar an méid atá ráite, bhí ríméad ar gach éinne nuair a foilsíodh an fís seo i mí Eanáir 2006. Bhí gach éinne sásta leis an méid a bhí molta agus socruithe le déanamh. Tá a fhios ag an saol go bhfuil géarghá le athordú iomlán sa chaoi ina gcuirtear seirbhísí ar fáil dóibh siúd le fadhbanna sláinte intleachtúil ar leibhéil éagsúla. Is léir gurb é atá sa doiciméid seo ná an cur chuige ceart. Mar a dúradh, bhí sé i gceist go mbeadh sé i réim agus i bhfeidhm faoi 2016. Is léir nach dtarlóidh sé sin muna bhfuil athrú sa chaoi ina bhfuil an Rialtas agus an HSE ag tabhairt faoi agus muna gcuirfí na hacmhainní caoi ar fáil. Tá cinneadh le déanamh anois os rud é nár tharla go fóill go leor de na rudaí gur chóir dóibh a bheith tarlaithe ag an bpointe seo. Tá súil agam go dtabharfaidh an Rialtas gealtanas go gcuirfear an fís seo i bhfeidhm roimh 2016.

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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I welcome the Minister of State, Deputy Moloney. As he noted in his presentation, he took up this job a little under two years ago. He is probably the best Minister with responsibility for mental health issues and disability we have had in a long time. I say this because he has put his political head on the block so many times. He says what he wants and promises to have it introduced by next March, for example, and then to do something else by the end of April. I have watched the Minister of State, whether before the Joint Committee on Health and Children every quarter, on "Prime Time", on a news bulletin or at some launch. He shoots from the hip but he speaks from the heart.

I commend the Minister of State because he is doing a very brave thing. I am glad Senator Fitzgerald acknowledged the work of the Minister of State and that there have been changes since he came into office. The Minister of State said on a number of occasions that the first thing he did on being appointed to office was to read himself into A Vision for Change. As Senator Corrigan said, it is good to start on a positive. We need to be positive when it comes to mental health issues and see the glass as half full rather than half empty. I am glad we have a mind and a pair of hands like the Minister of State's to steer this issue for us.

I have certainly seen changes take place. Eight years ago, when I came into the House, I was spokesperson on health and children. Those were the dark and dreary days when mental health was the Cinderella of the health service, if not the Cinderella and the two ugly sisters all rolled into one. Very little was happening at that time in this area but the Minister of State has taken it by the scruff of the neck and shaken it up.

I am glad the Minister acknowledged earlier that while he would expect support on his own side of the House, he would look for support from the Opposition benches as well. I have no doubt, having listened to Senators Mullen and Fitzgerald, that he will get that support.

Having observed what the Minister of State is doing and where he is coming from, and from talking to others, I know he has the support of the medical and nursing community as well as the public. When I met Dr. Tony Bates of Headstrong, he told me an interesting story of which I have no doubt the Minister of State is aware. At the Headstrong unit in Galway one day, Dr. Bates overheard a young man take a call on his mobile phone from a friend who was clearly asking him where he was. When he said he was down at Headstrong, the friend asked him where that was, thinking it was a pub or café. The young man replied that it was the place to drop into if a person has mental health issues.

That leads me to the whole area of stigma. As Senator Corrigan rightly said, it is lack of information and awareness that leads to stigma. However, young people of second and third level age do not have an issue with stigma. It is the older members of society who have been reared with this stigma and who carry it on.

As I said in the House the day after George Lee resigned from politics, if one eighth of the media coverage given to him could be given to the stigma that surrounds mental health, it would alleviate the sorrow and suffering of hundreds of thousands of people on this little island, not to mention worldwide. It is a problem that follows mental health issues worldwide.

I would love to think this issue would be taken up by the members of the media, who are at this moment talking about how the new Ministers feel about their new appointments, and whether they are happy or unhappy. They are talking about one particular female Minister and saying she must be grossly unhappy. I have just met her, and she is jumping over the moon she is so delighted with her new portfolio and looking forward to the challenge.

Photo of Jerry ButtimerJerry Buttimer (Fine Gael)
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She would say that to the Senator.

Photo of Rónán MullenRónán Mullen (Independent)
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Which one is that?

Photo of Geraldine FeeneyGeraldine Feeney (Fianna Fail)
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I wish the media would take up the issue of banishing the stigma that is attached to mental health. It would make the Minister of State's job much easier if the media would do that but they are not interested in that type of a story.

I know there are some, such as Miriam O'Callaghan, who are very interested in mental health, and I take my hat off to her for the wonderful "Prime Time" programme on this issue. The Minister of State was also on that programme and I admire and respect him for acknowledging there is still much to do. His words today were that he is sorry the reform of A Vision for Change has not been fully achieved. However, we are not even halfway through our term with that seven to ten-year programme and, hopefully, under the Minister of State's stewardship, it will be achieved.

As the Minister of State knows, one in four people will be affected by mental health issues throughout their lives. Whether we like it, this affects every one of us because one in four is a very large number. It will be somebody in my family, Senator Buttimer's family or the Minister of State's family - we will all be affected by it.

I am thrilled to hear the Minister of State say the community-based model is the way to go, which it of course is. I had occasion two years ago to visit a person in the psychiatric unit in Portlaoise in the Minister of State's constituency. I was amazed and proud that we could have such an excellent unit as the one in Portlaoise, which is in the grounds of and part of the general hospital, as opposed to the awfully antiquated place I knew of as a child. Growing up in Tullamore, I remember hearing that so-and-so is "in Portlaoise". People did not even mention the mental hospital; they simply said somebody was "in Portlaoise" and it was known where the person was.

The stigma surrounding mental health must be done away with. I have met people who are afraid to tell their employers or managers that they have mental health issues and are being treated for depression because they know it will not look good on their employment record. Such people have been penalised and victimised when they have told that they have mental health issues.

I ask the Minister of State to keep up the excellent work he is doing. People with mental health issues are very vulnerable and if anybody is to give them reassurance, he is the one to do so. I ask him to keep out there and to keep talking the way he has been talking. We might arrange for the Minister of State to come to the House to have this type of debate every quarter. We have been asking for this for a long time because there is never any harm in bringing issues to the fore from time to time.

Photo of Jerry ButtimerJerry Buttimer (Fine Gael)
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I commend the Minister of State for his commitment to his job and, in particular, his account on the "Marian Finucane" programme which touched many of us. While I would not jump into bed with Senator Feeney in calling him the best Minister of State at the Department for Health and Children, he has a very positive approach and commitment to the job. I hope the Government will give him the necessary commitment.

World Health Organization statistics show that Ireland has the fourth highest rate of suicide in the age range of 15 to 24 years in the European Union. As Senator Feeney correctly stated, the members of the Cabinet are out on the plinth talking about the reshuffle when the reality is that 95% of the people do not care about it. Fellow citizens are under pressure, unable to cope and struggling. I refer to the Minister of State's remarks about the need to have person-centred recovery measures in mental health services. We must protect and support all citizens. I have said before in the House that we need to support young and middle-aged men who are very vulnerable and feel isolated and alone, either as a result of losing a job or financial pressure; men who are struggling and cannot cope with being gay; men whose relationships have broken down; men who are left powerless and vulnerable for a plethora of reasons. It is important we strike a note of solidarity with them.

I commend all those involved in the mental health services. I worked as a hospital porter and had the pleasure - I use that word deliberately - of working with patients in Cork University Hospital, formerly Cork Regional Hospital. Men especially were struggling with issues in their lives and I learned to appreciate what life has to give. We are very fortunate to have our mental health and can come here tonight and act as advocates and be a voice for people. As Senator Corrigan correctly said, we must de-institutionalise old psychiatric buildings and close them down. In so doing, it is important to apply the concept of assisted living in its holistic sense and look at the role of the inspectorate. We should not just move patients without joined-up thinking. We must join the dots, so to speak, and put people at the core. We must ensure adults with an intellectual disability are not lost.

I have a concern that the figures in the financing of A Vision for Change are unrealistic. The Minister of State stated €25 million had been given to the HSE prior to 2009. What will happen to the remaining buildings that have not been sold? Who will buy them? There is a downturn in the economic value of property. If we are moving away from institutional care which is the right policy, we must look at patients in these hospitals. We are all aware of individuals who should never have been placed in them and suffered badly. I hope the community support services will have the capacity to meet their needs and that significant funding will be available.

It is four years since publication of A Vision of Change. The Minister of State has stated honestly that its implementation has been slower than anticipated. Dr. Siobhán Barry referred to the need for 1,803 new staff and stated this could take 40 years. While I am not an expert, does the Government know what it is doing and where it is going in the context of implementation of A Vision for Change?

I welcome the Minister of State's remarks regarding the campaign against stigma to be launched in April. I commend his personal commitment. While I do not question his energy in the Department, I question the commitment of the Government to the fulfilment of the aims of this policy document in terms of the sale of buildings, ring-fenced funding, the provision of staff, the role of the inspectorate and the funding mechanism to be put in place.

I was struck by the Minister of State's remarks about citizenship but we still have a long road to travel. I compliment Amnesty International and the children's mental health coalition on their excellent presentations to us in recent months. We need to steer a new course. There needs to be youth participation in schools in order that young people can become voices for change in the way in which mental health is viewed. This is not an issue about beds or institutions. It is not about physical buildings but people. This has to be at the core of our thinking, although it may seem like a very simplistic approach. In any town or rural area there are people who are walking around aimlessly and have no sense of the contribution they are making to society. They feel vulnerable, alone and isolated. They do not think there is support available to them or that there is someone available to help them. We all meet people in our offices every week who are looking for help in seeking housing or filling in basic forms. Many bureaucrats view them as a nuisance or as being four sheets in the wind, so to speak, and dismiss them. The Minister of State is the primary driver of the vehicle. He must ensure we build a coalition to engage in implementation of A Vision for Change. The time for rhetoric is over. The children's mental health coalition made some very interesting points in the four key areas - the four pillars - which include the education system, the criminal justice system and the care system.

I pay tribute to Mr. John McCarthy in Cork and his Mad Pride campaign which has taken advocacy to a new level. I also thank the Minister of State for his work. He is but one part of the wheel which is in need of an overall and an over-arching Government commitment which I hope will be given.

Photo of Mary WhiteMary White (Fianna Fail)
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I welcome the Minister of State and wish him continued success in his mission to improve mental health services and achieve a reduction of the stigma attached to depression and mental illness.

I will focus on older people and mental health. Depression is the most common mental health disorder in later life, affecting between 10% and 15% of people aged 65 years and over. Older people suffering from depression can be affected by feelings of sadness, loneliness, rejection, failure, hopelessness or a combination of these. Depression, however, is not an inevitable part of growing older. Its prevalence among the old is often linked to the increased likelihood of losing loved ones, retirement, the loss of independence or chronic illness. An increased suicide risk has also been identified, particularly for older males, among whom there is a relatively high rate of completed suicide, often through indirect means, such as starvation, dehydration or failure to take important medical drugs.

Older people are often reluctant and embarrassed to describe psychological or emotional issues. As part of the Government's mental health strategy for the future, we need a targeted health promotion campaign that focuses on mental health issues among older people and that highlights the fact that depression is not a natural part of aging. This should include increasing awareness among older people and their families and friends of the warning signs of depression and other mental health problems.

A key to mental health disorder prevention is preparation for the changes that occur in old age, such as retirement, bereavement and poor health. Programmes designed to develop self esteem and coping skills, and counselling for those undergoing change, are important tools that can be used as part of an overall strategy.

We must also increase older people's access to the treatments that are available. Early detection and treatment can lead to significant improvements in mental health and quality of life. If we fail to deal with the mental health of older people, we will fuel a lack of understanding of depression, leaving many older people affected by the illness, undiagnosed and untreated.

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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It is fitting that, as we speak, Deputy Dan Neville and Miriam O'Callaghan are launching two books related to the issues surrounding suicide and mental illness. I wish them well.

I am disturbed at the way we link any success in A Vision for Change to the remnants of a collapsed property market. Any money from the sale of properties in the mental health service in the last four years went back to general Exchequer funds and if the money was given to the HSE it could have spent it on anything. If some of the properties that are now being put up for sale had been sold in the last four years, they would be moved into NAMA in the coming weeks. In some respects, therefore, the mental health services are lucky some of this property is still in their ownership because at least the madness of the property bubble has dissipated.

The property associated with mental health institutions, however, should not be seen as the only reason to improve the mental health service. Those services are disastrous, to put it mildly. In County Wexford, St. Senan's Hospital should have been closed years ago but when I called for it to be closed, there was no great support from other public representatives. They did not understand how backward facilities are in some of these institutions.

At the same time, I am not keen on the plan envisaged at the moment. Under that plan, patients from County Wexford must now go to either Carlow or Waterford to receive treatment and the Government has no plans to build an acute unit on the grounds of Wexford General Hospital. That is another backward step because while many patients can be treated in the community, there is a need for an acute admissions unit for those who suffer an acute psychiatric crisis. They need immediate help and proper inpatient care when such a thing happens. A large unit would not be necessary, things have moved on, and patient stays in acute units can be considerably shortened. There should, however, be an acute unit on the grounds of Wexford General Hospital because we have a population of 100,000, with a huge transient population. In the past I have dealt with acute psychiatric crises among those passing through the county. That can be more difficult because they have no family support or company when the episode occurs and there is a need for immediate transfer.

The Minister of State must also look at the way patient transfers are currently being carried out. There were massive problems with the old system, where a family member and I could sign a pink form and a patient would be bundled into the back of a squad car and taken to St. Senan's. That is no way to do things. There can, however, be significant delays. We take a certain risk, often waiting overnight, before the HSE team arrives to make an involuntary admission to a psychiatric hospital. I would be concerned that if St. Senan's closed completely and the delays that can happen with the HSE team at present continue, we could find ourselves in a worse situation with those patients who most need the highest level of care during a crisis. The Minister of State should ensure the rules are changed to protect those patients.

I have not had the opportunity to go through the Minister of State's speech in detail but the child and adolescent mental health teams are often under-resourced. There may be a doctor and a nurse but they do not have the full team required to look after patients with mental health problems in the community. If those people are not properly looked after, we are only wasting our time, putting their lives at risk while not giving them the care they need, leading to them being placed once more in inpatient institutions. The whole community project then fails. These must not become "ghost" teams, like the Minister for Health and Children's primary care teams, that only exist on paper. The Minister of State must do this properly.

If the Minister of State wants care for mental health patients in the community, it must be done properly. If he wants to provide proper inpatient care for those undergoing an acute crisis, we can settle for less but it must be funded from general Exchequer funds. we cannot rely on selling properties that no one wants these days.

I hope we do not end up with a situation like one I am dealing with at present, where a 16 year old boy who broke his hip on St. Patrick's Day is lying in a hospital bed in Waterford waiting for a transfer to a Dublin hospital for an operation. To be dealing with a such a situation in this day and age is madness. That is happening in the general medical service, an area people understand, but there are worse situations in the mental health services that are being provided across the country. People, however, do not understand that unless they are caring for an individual who has these problems.

Photo of John MoloneyJohn Moloney (Minister of State, Department of Education and Science; Minister of State, Department of Health and Children; Minister of State, Department of Enterprise, Trade and Employment; Minister of State, Department of Justice, Equality and Law Reform; Laois-Offaly, Fianna Fail)
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): I thank Senators for holding this debate. It will be difficult for me to answer all questions in ten minutes, because ten Senators contributed and most asked at least five questions.

I would welcome the opportunity to come back more often, and I will take up the recommendation from Senators Corrigan and Feeney that there should be quarterly sessions to gauge progress. I hope that not many patients are listening to this debate because it would lead them to wonder whether their chances of living better lives have improved. I take a very positive attitude to my current job and hope I will take the same attitude to any other Department to which I am appointed. I was staggered to hear the claim that it will take 40 years to reform mental health services. I wish to rehearse a number of points for those who take an interest in these matters.

I cannot believe that certain Senators have suggested we do not have a director of mental health services. Mr. Martin Rogan was appointed to this position six months ago. The appointment is in itself a fundamental step towards delivering the reform programme. The appointment of regional directors represents another important part of our agenda.

It was never the Government's intention to depend solely on the sale of properties. The fact that I have had to repeat this point so often goes to prove that mental health is not really the issue. I have repeatedly stated at press conferences, meetings of the PNA and public consultations on the reform programme that a combination of sales of properties, the voluntary sector by way of the Irish Council for Social Housing and primary care centres for community mental health teams will reduce the overall cost initially for delivering A Vision for Change.

As Chairman of the Joint Committee on Health and Children, I dealt with the issue of the high incidence of suicide in this country, which is part of what we are discussing today. I have tried to offer hope that modern services will be made available throughout the country to provide proper support. Unlike some Senators, I have had the opportunity to learn first-hand about the huge strides that have made. I am glad mention was made of Galway. I am pleased to know that the first two Headstrong facilities are in place and that a commitment has been made to fund 20 centres by 2016.

I thank Senator Fitzgerald for her very positive attitude but assure her that funding for mental health services is ring-fenced and €50 million has been committed each year from the sale of properties. I am disappointed that people are putting out the nonsense that we will not be able to sell the properties concerned. How many more negative arguments must be made against the people who are trying to get out of institutionalised care? In respect of the ten properties we originally targeted, there is a real interest in ensuring we deliver on our €50 million commitment.

In regard to the role of other Departments, a commitment has been made to employ 7,000 people with disabilities, including in the area of mental health, by the end of 2010. We have already exceeded the figure of 5,000 and by working together our Departments will show how we can deliver the remaining 2,000 jobs.

In the area of housing, I have a track record from providing a 28-unit scheme for the elderly in my home town of Mountmellick, and a planning application has been submitted for a 30-unit scheme which will incorporate housing for people with mental health issues and disabilities. Rather than focus on negative aspects, why can Senators not be more proactive in offering leadership in closing hospitals in their own communities? This will not depend on the sale of properties. Of the 1,200 people accommodated in the old mental hospitals, 70% can live in the community. If Senators really want to deliver on A Vision for Change, they should not spend their time wondering how many community mental health teams are in place. Let us develop proposals with our respective local authorities for providing facilities. I give my commitment that the HSE will offer that level of support to each individual patient transferring out of mental hospitals.

Senator Ó Brolcháin raised the issue of equality across the regions. I accept that certain parts of the country offer excellent supports in terms of community mental health teams and local mental health groups. I also acknowledge Senator Boyle's suggestion on section 59(b) of the Mental Health Act. Last December, I gave my commitment to the Dáil that the heads of a Bill would be prepared by June.

Senator Mullen spoke about delays in the sale of properties. I again emphasise that A Vision for Change was never predicated on the sale of properties. The mental health portfolio includes 800 properties and rather than send people the message that it is simply a case of mirrors and smokescreens, I am repeating the specific commitment I gave when I first addressed the Seanad on this matter as Minister of State that we will show how we can deliver on this concept within 12 months. I am aware of the abilities of Professor Siobhán Barry but I assure the House that I have my own abilities. I do not believe for one minute that 40 years will be required to deliver on our programme.

In regard to the question of whether the policy originates from the HSE or the Department of Health and Children, I have clearly outlined my role in driving it with support from both of these bodies. The evidence for this includes the appointment of directors, the development of an implementation plan and, more importantly, the use of primary care centres to deliver modern mental health facilities.

I am all for openness and transparency. I am prepared to appear before this House every quarter as well as the Joint Committee on Health and Children. Nobody asked me to explain my plans to the public at Farmleigh last March. I chose to outline how this Government, in co-operation with all the agencies, can deliver A Vision for Change. I wish people would read the foreword to that document before they criticise it. It does not state, for example, that the programme will be delivered in year one, two or three. The service providers at the coalface recognise that it is a ten-year programme. It is nonsense to suggest that we have failed because we have not yet provided 100 child and adolescent beds. We are halfway through the programme.

The reforms are not about the capital programme or the level of spending, even though these are important elements. I often hear criticisms from politicians who are not at the forefront of delivering reform. I am thinking in particular of the need to reduce the sigma associated with mental health. In recent weeks, several people in high profile jobs have told me about the difficulties they endure every day because of their fears of being found out. I wish to throw out a challenge to the media in this regard. On 15 April, I will bring forward proposals at the Mansion House, with the help of John Saunders and other committed people, on a reform programme that will turn the tide of people's attitudes towards mental health. I invite members of the media to come on board for that programme. It is a not a one-day event; it is a two-year programme with the capacity to drive real change in terms of persuading people that mental and physical health should be judged the same way.

I would love to see the day when a specific percentage of the overall health budget is committed to mental health. Our focus should be on building a platform so that we can set out the specifics to the Government. However, I am not taken by the notion that funding for mental health services is being continually eroded. I am certain Senator Twomey is aware that some 90% of people with mental health problems present at primary care level. Funding has been delivered through the primary care process. I never once stated that enough is available.

Senator Prendergast raised the matter of Clonmel and I am surprised at her comments. I travelled to Clonmel. Then I came to the House to hear the complaints about the HSE, comments which I do not support. I support the HSE. The idea of attacking the HSE in some cases to make one popular on the ground is not my way of doing things. I supported the HSE when it came to the cancer issue in my constituency and I supported the opposite county. This is why I am surprised. I gave a commitment in the House that rather than simply believe in my own prepared script I would go down to Clonmel to listen to the public representatives and the consultant staff, and I did so. I am beginning to wonder whether this took place. Now questions have arisen about whether I knew my brief or signed off on something. I have news for Senator Prendergast because obviously she turned off while I was discussing this matter. I suspended the meeting in Clonmel and stated I was prepared to accept the word of the public representatives. I informed them that I would return to Dublin and check on the process of how the decision was arrived at. I gave a commitment to each of the public representatives, including Senator Prendergast. However, the Senator prefers to play to her local gallery rather than discuss the matter in terms of a national programme.

Photo of Paddy BurkePaddy Burke (Fine Gael)
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We are running out of time.

Photo of John MoloneyJohn Moloney (Minister of State, Department of Education and Science; Minister of State, Department of Health and Children; Minister of State, Department of Enterprise, Trade and Employment; Minister of State, Department of Justice, Equality and Law Reform; Laois-Offaly, Fianna Fail)
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As requested, I gave a commitment that nothing would happen in Clonmel until the public representatives involved had an opportunity to meet a Minister. I stand over that commitment but this evening it is as if that never happened and I wonder about the bona fides of the comments the Senator made regarding me.

Photo of Phil PrendergastPhil Prendergast (Labour)
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I have an answer if the Minister of State wishes to hear it.

Photo of John MoloneyJohn Moloney (Minister of State, Department of Education and Science; Minister of State, Department of Health and Children; Minister of State, Department of Enterprise, Trade and Employment; Minister of State, Department of Justice, Equality and Law Reform; Laois-Offaly, Fianna Fail)
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People in the service maintain and I have always believed that it is not all about money or staffing levels. It has been suggested in this debate that we need an extra 1,403 staff. People refer to A Vision for Change as if they read it letter by letter. A Vision for Change explicitly states that 5,400 nurses are working in institutionalised care and the transfer to modern community facilities would require 2,800 nurses. Unfortunately, the people I have visited in hospitals may listen to the negative comments passed here this evening. I intend to send a message back to them that I believe my job is to treat this as a positive commitment to the reform programme, which we are only half way through. However, given the Government commitment and the capital programme we will see that commitment delivered in A Vision for Change.

Photo of Phil PrendergastPhil Prendergast (Labour)
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I wish to address one point made by the Minister of State, who stated I am playing to some local gallery. I am playing to no local gallery whatsoever. I read out an appraisal document and I wish to know whether the Minister of State stands over it. Does he believe it is acceptable?

Photo of Paddy BurkePaddy Burke (Fine Gael)
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The Senator has made her contribution.

Photo of Phil PrendergastPhil Prendergast (Labour)
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I have the highest regard for the Minister of State as a Minister of State and as a person but I do not consider that having faith in the HSE, which makes these decisions, is satisfactory.

Photo of Paddy BurkePaddy Burke (Fine Gael)
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The Senator has made her contribution.

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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On a point of order, I understood this would be a two way process in regards to the question.

Photo of Paddy BurkePaddy Burke (Fine Gael)
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The Senator should note we are out of time.

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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I am only asking-----

Photo of Paddy BurkePaddy Burke (Fine Gael)
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I am bound by the Order of the House.

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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If it is, I invite the Minister of State to come to St. Senan's with me and we can hold a good discussion about what to do with the mental health services in County Wexford.

Photo of Paddy BurkePaddy Burke (Fine Gael)
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The Senator should note that I am bound by the Order of the House.

Photo of John MoloneyJohn Moloney (Minister of State, Department of Education and Science; Minister of State, Department of Health and Children; Minister of State, Department of Enterprise, Trade and Employment; Minister of State, Department of Justice, Equality and Law Reform; Laois-Offaly, Fianna Fail)
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I have been to St. Senan's.

Photo of Liam TwomeyLiam Twomey (Fine Gael)
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I am asking the Minister of State in a very non-partisan way.

Photo of Paddy BurkePaddy Burke (Fine Gael)
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I am sorry we are out of time. I am bound by the Order of the House. When is it proposed to sit again?

Photo of Maria CorriganMaria Corrigan (Fianna Fail)
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On Wednesday, 24 March at 10.30 a.m.