Lynn Ruane (Independent)
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In the 1950s Ireland held the world record for the number of people detained in psychiatric institutions. Thankfully, the majority of the older style Victorian hospitals are now closed and the focus of mental health services is on treating people in the community as close to their homes as possible. In the 1980s, 24-hour supervised residences were opened to accommodate service users who had resided in the old-style psychiatric hospitals, many for long periods. Accordingly, these residences are their homes. It is recommended that such homes be confined to having no more than four residents. However, 40% of the residences inspected by the Inspector of Mental Health Services in 2015 had more than 13 beds. It is important to note that these service users are particularly vulnerable, as many of them have been living with long-term mental health difficulties within institutional settings for most of their lives. However, rather than benefiting from a move to community care, they have, in essence, been forgotten and abandoned by the modern health system which has simply moved from larger to smaller institutions.

Crucially, we do not know how many people are living in these conditions or how many of these residences there are. In its 2015 annual report the Mental Health Commission stated there was a fundamental issue with identifying precisely the number of residences, as well as the number of people living in them. Despite repeated discussions with the HSE, no agreement has been reached on the issue. Additionally, the commission is concerned that some of these residences are too large, have poor physical infrastructure, are institutional in nature and lack individualised care plans. Under the Mental Health Act 2001, the inspector can visit these facilities and report on his or her findings. A service can be requested to provide a quality improvement plan.However, under current legislation, these facilities are not subject to regulation by the Mental Health Commission. This means the Mental Health Commission has no statutory powers over them, unlike inpatient units, which the Mental Health Commission can close down if they breach certain standards of care. The expert group established to review the Mental Health Act 2001 made the following recommendation:

The new Act should give the Mental Health Commission specific powers to make standards in respect of all mental health services and to inspect against those standards. The standards should be made by way of regulations and the regulations should be underpinned by way of primary legislation.

In 2015, the Mental Health Commission inspected 20 24-hour supervised residences. The 2007 HSE report on accommodation for people with disabilities, Time to Move on from Congregated Settings - A Strategy for Community Inclusion, recommends that home sharing arrangements should be confined to no more than four residents in total and that those sharing the accommodation have, as far as possible, chosen to live with the other three people. Some 55% of HSE mental health service 24-hour supervised residences inspected in 2015 had more than ten beds and 40% had more than 13 beds. According to these inspections, only six out of 20 residences inspected were described as in good decorative order, comfortable and homely. A number of residences were institutional in function and environment. For example, chairs were lined up against the walls in a row, bedrooms were devoid of personal possessions, shower facilities were locked, residents were not allowed to lock their wardrobes or bedroom doors.

Only seven, 35% of the residences, had exclusively single bedrooms while 12 had double bedrooms, ten of which had no provision for individual privacy. One residence had two four-bed rooms. The inability to provide residents with a single room impacts on their privacy and dignity. With reference to one of the residences, the inspector reported that the overall state of the residence was poor.

It is recommended that all residents have a yearly medical assessment. In ten of the 20 residences inspected in 2015, the residents had a six-monthly medical check with their GPs, in six residences there were annual medical checks, while in four the residents did not attend a scheduled medical check and attended a GP only if they became unwell. In 14 residences it did not appear that the residents were means tested for charges, and each resident paid the same charge.

In summary, the Mental Health Commission stated that many of the residences inspected were too big, in poor condition and institutional. There was limited multidisciplinary input in over 50% of the residences inspected. Some residents had no care plans or any meaningful activity to occupy them during the day. Many 24-hour supervised residences were failing to provide opportunities for the optimal recovery and rehabilitation of their client populations, as outlined for them in A Vision for Change, which has been in operation for ten years. Recovery in this context reflects the belief that it is possible for all services users to achieve control over their lives, recover self-esteem and move towards building a life where they can experience a sense of belonging and participation. The guiding principles relevant to the housing needs of individuals with mental health difficulties should include citizenship, equity of access, community care including specialist mental health support, co-ordination of support and inclusiveness. The provision of community residential care for vulnerable mentally ill people, who may not be in a position to articulate their wishes, must be on an equal basis with other citizens and such provision should be a priority.

In 2008, the HSE conducted an evaluation, in accordance with the guidance for value for money and policy reviews, of the efficiency and effectiveness of long-stay residential care for adults within the mental health services. The report found wide variations in resource allocation, a significant minority of clients were deemed to be inappropriately placed, low levels of discharges from long-stay residential services to lower level supports and a lack of consistent understanding of or approach to rehabilitation among the residences. I have more to say, but given that I must conclude, I will send it to the Minister of State.

Paul Coghlan (Fine Gael)
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The Senator will have to write a letter. She seems to have many pages.

Helen McEntee (Meath East, Fine Gael)
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The best thing would be to arrange a meeting to discuss it. I thank the Senator for her detailed analysis of many problems that exist. There is widespread acknowledgement that there are many problems that must be addressed. Mental health continues to be a priority for the Government. It is reinforced by the fact that funding is increasing and we have given a commitment to continue to increase it. This will be paramount to how we can progress and address many of the issues the Senator raised.

The Mental Health Commission Annual Report 2015 reflects the widely accepted need to further develop a community based mental health service, with a prevention and recovery focus, as outlined in A Vision for Change, which, as the Senator said, is ten years old. Given that it was to be reviewed after seven years, we need to get moving on it. The Mental Health Act 2001 provides that the inspector of mental health services visits, inspects and reports on every approved centre at least once every year. The inspector may also inspect any other service where mental health services are being delivered under the direction of a consultant psychiatrist.

The Report of the Expert Group on the Review of the Mental Health Act 2001 was published last year. The group recommended the Mental Health Commission develop a risk-based approach to inspection to ensure maximum effectiveness and efficiency in the use of scarce resources. The group was in broad agreement that inspections of approved centres should be proportionate, based on risk and take place at least once every three years. Annual inspections may be required if the risk profile merits such scrutiny. This would allow for community services to be registered and inspected at reasonable intervals using a risk-based system starting with all community mental health teams. Work on the general scheme of a Bill to amend the Mental Health Act 2001 and to include the recommendations I have mentioned is under way in my Department. I will take the Senator's suggestions and would welcome working with her on any of those.

In the context of ongoing development of community mental health teams, the HSE continues to promote prevention and recovery initiatives and enhanced service user engagement across the mental health services. This has been reinforced by my decision to commence a process of policy review for mental health, guided by research into international evidence and best practice in these areas. We should focus not just on mental illness but on health, well being and many other factors that contribute to it. Six approved mental health centres achieved full compliance with all regulatory requirements in 2015. While 55 centres were found to be non-compliant to varying degrees, 82% of these findings were small issues rated as having a low to moderate risk of recurrence, which can and, hopefully, will be addressed in the very near future. I have urged the maximum effort on the part of all non-compliant centres to meet the necessary requirements in 2016 and in this respect I welcome the introduction of the Mental Health Commission Judgement Support Framework to guide and assist approved centres to comply with the commission’s regulations, rules and codes of practice and to promote improved quality of services through a transparent inspection process. In light of the fact that it will take time and funding to improve it, we must give as much support as possible to the services to try to ensure they are as compliant as possible.

Funding for mental health in 2016 has increased from the 2015 outturn of €785 million to €826 million, an increase of €41 million, which includes the €35 million ring-fenced. This funding is used to develop the priorities for 2016, which includes improved counselling services across both primary and secondary care, continued development of community mental health teams, improved 24-7 response and liaison services, which needs to be a priority, psychiatry of later life, perinatal mental health, and two new mental health clinical programmes, namely, ADHD in adults and children and dual diagnosis of those with mental illness and substance misuse.

The Department of Health sanctioned the HSE to commence expenditure, and I have signed off on this for approximately €22 million of this year’s funding for new developments. It is expected that sanction in respect of the remainder of the funding will be signed off in the coming weeks

Lynn Ruane (Independent)
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I thank the Minister of State for her response. It is a large area and the Minister of State has probably already met with Mental Health Reform.

Helen McEntee (Meath East, Fine Gael)
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Yes, I attended its AGM.

Lynn Ruane (Independent)
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I was going to ask for that to happen.

Helen McEntee (Meath East, Fine Gael)
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I would welcome the opportunity to meet the Senator and go through some of the issues she has raised.

Lynn Ruane (Independent)
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I thank the Minister of State.