Mary Butler (Waterford, Fianna Fail)
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I am pleased to join Senators here in the Seanad to discuss the very important topic of child and adolescent mental health services. We had a debate in the Dáil for two hours yesterday and a further debate lasting three hours last Thursday to discuss the Mental Health Commission's report. I know the Seanad had invited me here prior to the publication of that report. I was happy to oblige. All of us in Government have listened most closely to the views and contributions expressed over recent days.I have welcomed the opportunity to address a number of issues raised by my Dáil colleagues over the past week.

The Government recognises the challenges facing CAMHS and the value of the findings highlighted in the Mental Health Commission's interim report on CAMHS. It is important to point out that, this time 12 months ago, I stood before the Seanad to discuss the Maskey report. As a result of that report, I asked the Mental Health Commission to expand its report on CAMHS. I funded that work in order that it would be able to report fully on all 73 CAMHS teams. It was important that I be provided with this relevant information to help me make the best changes possible to ensure that our CAMHS teams were working well throughout the country.

The findings of the interim report highlight areas where services can be improved to benefit CAMHS throughout the system. The Government remains fully committed to the delivery of a high-quality, safe and compassionate mental health service for all, which is reflected through the delivery of our programme for Government commitments on mental health. Therefore, I welcome this opportunity to highlight the services and supports available to young people experiencing mental health difficulties and their families. It is important to the Minister, Deputy Stephen Donnelly, the Government as a whole and me that young people are aware of the services available to them, as well as the work that is ongoing to improve CAMHS.

The Mental Health Commission's interim report is one of a number of reports and audits currently ongoing into CAMHS. They, the reports and audits arising from the Maskey report and the final report of the commission will serve to provide important information on how mental health services can be improved. They will also provide an opportunity to highlight good practice throughout the system and to share best practice. Nonetheless, and as the Minister and I indicated last Thursday and again last night in the Dáil, the interim report's findings identify several issues that are not acceptable to anyone. The Minister and I supported the commission in carrying out its annual thematic report into CAMHS. We await the final report on all nine community healthcare organisations, CHOs, and welcome the role the commission plays in ensuring high standards of service provision in our mental health services.

All areas of concern identified by the commission in carrying out its interim report were escalated at once to the HSE for immediate action and resolution, including the review of open patient cases that the HSE is undertaking. This will initially consist of a review of all open cases where the patients have been prescribed medication by their CAMHS consultants or doctors and who have not been seen in the past six months by their CAMHS teams. In addition, the Department of Health will work with the HSE to develop immediately a model of care for prescribing practices in CAMHS. This review of open cases will provide an assurance that these children and young people are receiving appropriate care that reflects their current and future needs. It will include a focus on physical health monitoring of those on medication.

Regarding the interim report's recommendation on regulating CAMHS, the need to regulate CAMHS has been built into the provisions of the upcoming revised mental health Bill. We all empathise with young people and their families who may be worried about receiving the care they deserve. Much good work is being done by our CAMHS professionals across the country, and it is appropriate to recognise their strong commitment to vulnerable young people and their families.

Recognising the challenges and concerns in this regard, it is important to note that the majority of young people who experience mental health difficulties have access to a variety of services and supports. Of those who seek care from CAMHS teams, the vast majority experience positive outcomes in terms of care and recovery. This is important work, as recovery is always possible.

Annually, CAMHS teams receive and triage nearly 21,000 referrals and deliver 225,000 appointments for children and young people requiring assessment and intervention. Between 2020 and 2021, CAMHS experienced a 33% increase in demand and saw 21% more cases with the same staffing levels. Currently, there are 80 consultant psychiatrists in post working across 73 teams. The HSE is continuously working to ensure that all funded positions are filled and staff are available to provide this important service.

Recruitment began this week for a new post of youth mental health lead at assistant national director level in the HSE. As opposed to just one post, four and a half whole-time equivalent posts will be associated with this. A further new post of national clinical lead for child and youth mental health has also been announced. Recruitment for it will start quickly.

We had an intense and passionate debate in the Dáil last Thursday and last night, with positive contributions overall from all sides of the House. We must always bear in mind that, while any deficiency in CAMHS needs to be acknowledged and addressed insofar as possible, we must also be conscious of the sensitivities and needs of those using CAMHS. The Government is accepting of constructive criticism, but we must all offer reassurance to the public and instil confidence in the strong and important health services that are operating every day. As we debate the report of the Mental Health Commission and other issues relating to CAMHS, I am conscious that there are children sitting in waiting rooms the length and breadth of the country and there are 73 fantastic CAMHS teams working. The children's parents are also supporting them. We must be conscious of these factors. It is important for me as Minister of State to be able to build confidence in the CAMHS structure. A balanced and evidence-based approach, including listening to the lived experiences of service users, is always the best way to analyse concerns collectively and find the solutions we all seek.

Real change in mental health services has been under way in recent years and will continue through implementation of the widely agreed Sharing the Vision policy. There is a record €1.2 billion allocation in 2023, representing a significantly increased investment by the Government of €220 million since June 2020. Importantly, dedicated funding for CAMHS is administered as part of the overall HSE mental health allocation every year. In addition, funding has been provided for two new CAMHS telehubs and there is a dedicated €6 million to expand the capacity of community mental health teams nationally, with a particular emphasis on CAMHS.

For those who need access to the specialist supports and services that CAMHS provides, it is acknowledged that children and their families can experience varying waiting times. Some 93% of urgent referrals to CAMHS are responded to within three days. Steps are also being taken to reduce waiting times actively. In collaboration with local CAMHS, a waiting list initiative is under way in six CHO areas, specifically targeting areas where children and young people have waited for longer than nine months. Focusing on the specific issues impacting each area, one-off funding of more than €1 million was allocated in May for CHOs 1, 2 and 7 and €1.23 million was allocated in June for phase 2 in CHOs 6, 8 and 9. Targeted activity is also being used to reduce waiting lists for primary care services. Up to the end of 2022, waiting list initiatives in primary care psychology services have resulted in a reduction of more than 3,500 young people on these waiting lists. These important and welcome initiatives ensure that young people access care supports as early as possible. For every one child leaving the list, though, two more are presenting. The number of presentations we are seeing makes for a difficult situation.

The continued reduction in the number of children admitted to adult units is a priority for the Government. In 2022, 20 young people of 16 and 17 years of age were admitted to adult facilities. The majority of them stayed for less than five days. Such admissions took place for a variety of reasons, including clinical decision-making and geographical considerations. On foot of recommendation No. 36 in Sharing the Vision, a youth mental health transition specialist group has been established by the HSE and is focusing on a more seamless transition for young people and integrated care pathways. Work by the Department of Health and the HSE to respond to the recommendations of the Maskey report is ongoing.

The new mental health Bill has been selected for priority drafting for the spring season and work is continuing on introducing it in the Oireachtas as early as possible this year. I look forward to taking the Bill in the Seanad soon. I hope for Senators' support for this large piece of work.

I wish to take this opportunity to mention the Mental Health Commission's important and independent role in supporting and assisting us in developing and improving mental health services.

Lorraine Clifford-Lee (Fianna Fail)
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Tá fáilte roimh an Aire Stáit. Tá an-áthas orm go bhfuil an deis againn inniu an tseirbhís ríthábhachtach meabhairshláinte CAMHS a phlé léi. Tá go leor plé déanta againn, mar a luaigh sí, de bharr fhoilsiú thuarascáil Maskey le déanaí agus leathnú an athbhreithnithe. D’iarr an tAire Stáit an t-athbhreithniú sin a leathnú. Níl againn ach tuarascáil eatramhach faoi láthair ach is léir go bhfuil fadhbanna in áiteanna áirithe fós. Cé go bhfuil a fhios againn go léir na fadhbanna a luadh i dtuarascáil Maskey agus sa tuarascáil eile, is fiú iad a lua arís. Ina measc bhí diagnóis neamhiontaofa, oideas míchuí, drochmhonatóireacht ar chóireáil agus go leor leanaí i mbaol dochair shuntasaigh. Tá sé dochreidte i ndáiríre. Bhí ionadh agus uafás ar go leor daoine óga agus a dtuismitheoirí faoin tuarascáil sin. Tá siad ag brath ar CAMHS ag am an-deacair ina saol. Níl sé maith go leor nach gcuirtear cúram den scoth ar fáil dár ndaoine óga ar fud na tíre. Bíonn an-eagla ar thuismitheoirí go minic nuair a bhíonn deacrachtaí meabhairshláinte ag a bpáistí. Uaireanta ní bhíonn a fhios acu cá bhfaighidh siad an chabhair agus an tacaíocht. Tá sé an-tábhachtach gur féidir leo an tacaíocht sin a fháil ó CAMHS go tráthúil agus gur féidir leo muinín a bheith acu as an tseirbhís. Is léir ón tuarascáil níos leithne go raibh eispéireas an-dearfach ag go leor páistí agus a dtuismitheoirí. Is léir freisin go bhfuil na gairmithe sláinte atá ag obair sa tseirbhís tiomanta dá n-othar agus go bhfuil siad ag obair go dian gach uile lá ar son na bpáistí agus ar son na dtuismitheoirí freisin. Úsáideann breis agus 20,000 duine óg CAMHS in aghaidh na bliana agus bíonn eispéireas dearfach ag formhór dóibh. Tá sé suntasach gur tháinig méadú 33% ar atreoruithe, rud a rinne an tAire Stáit tagairt do, agus tháinig méadú 20% sna cásanna lenar déileáil CAMHS ag an leibhéal céanna foirne. Tharla sé sin in 2020, nuair a bhí an-chuid brú ar an gcóras sláinte. Tá sé suntasach agus is fiú é a lua arís. Tá a fhios agam go bhfuil an tAire Stáit tiomanta d'fheabhsú seirbhísí mheabhairshláinte sa tír seo, go háirithe CAMHS. Tuigim go dteastaíonn an tuarascáil dheireadh uainn, atá le teacht i mBealtaine, chomh maith leis na trí iniúchadh eile, chun pictiúr iomlán a bheith againn. Is féidir dul i ngleic leis na fadhbanna i ndiaidh dúinn an pictiúr iomlán a bheith faighte againn. Tá na páistí ag iarraidh an tacaíocht atá de dhíth a fháil anois. Tá súil agam leis an tacaíocht sin go mbeidh siad in ann ag bogadh ar aghaidh lena saol. Tá sé deacair orthu ach tá súil agam go mbeidh siad in ann é sin a dhéanamh leis an tacaíocht chuí. Is gá caighdeánú, atreorú agus cúram CAMHS a chur ar fáil ar fud na tíre. Go n-éirí an t-ádh leis an Aire Stáit leis an obair sin. Tá sí de dhíth.

Sharon Keogan (Independent)
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I thank the Minister of State for being here, and I thank Senator Clifford-Lee for her contribution. I love hearing Gaeilge in the Chamber. I wish I could speak it but I cannot.

Lorraine Clifford-Lee (Fianna Fail)
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It is just about practice.

Sharon Keogan (Independent)
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As I sat down to think about what matters needed to be raised here this afternoon, I wondered what it is about health, mental health and child and teenage care that has not been said in the past ten years. I do not think a month goes by without this issue being raised in this Chamber, and I support that. It is certainly an issue of national importance and deserving of our attention but our proclamations or statements are worth nothing if they do not lead to action that will make a difference for people on the ground.

I tend to see very little evidence that disproves the impression that many people have of the HSE, that it is an unchangeable monolith, bloated by middle management and mired in bureaucracy. Last week, Professor Martin Curley, the appointed head of digital transformation in the HSE, said that the executive had no vision for the digitalisation of the health service and efforts to change this are being impeded by bad actors. It is a perfect snapshot of the system. Efforts to grow, change for the better or, God forbid, revolutionise some aspect of the service are not met with an understanding of the need for assistance in realising change but are disrupted and blocked at every turn by senior administrators who watch Ministers come and go and who, every four years, get a new programme for Government to use as a doorstop. We are pouring more and more money in and the results are getting worse, according to Professor Curley. We are spending the equivalent of what and or Austria are spending but our performance is far poorer. We are a world-class spender on healthcare for what is certainly not a world-class service. This is not due to the people on the ground, our nurses, doctors and healthcare assistants who are giving everything they have and are being stretched to breaking point every day. It is due to fundamental flaws at operational level and to middle to high-ranking pencil pushers for whom the only change that matters is to their salary or pension.

This is the backdrop against which our statements on the provision of child and adolescent mental health services in this State are being made. It is also the answer to so many of the questions heard previously and being posed again today. Why has X not happened? Why has Y not been progressed? Why are families still having to deal with Z? It is because the health system does not work and no Minister seems to have the power to change that.

Last week we saw the publication of the interim report arising from the independent review of CAMHS. It found that across the country, children and young people accessing mental health services were open cases and had been lost to follow-up care. In many cases, children were reaching their 18th birthday with no planning, discharge or transition to adult services or any advice about medication. Others were without any appointment for two years or failed to receive any appointments for a review of prescriptions or monitoring of medication. Evidence was found that some teams were not monitoring anti-psychotic medication in accordance with international standards. Children were taking medication without appropriate blood tests and physical monitoring. The report also identifies significant staff deficits across many HSE teams and CHOs. Team members were working beyond their contracted hours, often without compensation, in order to continue to provide a service. There was evidence of stress and burnout in a significant number of team members.

We were not even supposed to see this report. The inspector, Dr. Susan Finnerty, had planned to wait until the full report was completed later this year but decided to publish the interim report due to the serious concerns and consequent risks for some patients that were found. These were not few and far between, cherry-picked examples. Four out of the five CHOs that have been examined so far require urgent and targeted action in order to address the ongoing risks relating to them. The report also found long waiting lists, wide variations in acceptance rates, unacceptable variations in care, and a lack of capacity to provide appropriate therapeutic interventions. It found absent or poor care planning, a lack of CAMHS emergency and out-of-hours services, staff shortages, a lack of clinical governance and a lack of joint working with other agencies. The report also references a lack of child-centred care and administrative support, as well as a lack of ICT systems. The good news is that on foot of the interim report, the CEO of the HSE has committed to conducting a review of all open cases in all CAMHS teams, with a particular focus on identifying and accessing open cases of children who have been lost to follow-up and physical health monitoring of their medications.

We have had our statements. Knowing what needs to be done has never really been the problem. The problem lies in the doing. If it does not get done and if these problems remain unaddressed, the consequence will not be that we report a quarterly loss or that a party takes a hit in the next opinion poll. It will be more dead children and teenagers and many broken hearts and broken families. Preventing that might be worth rattling the HSE. One thing I find absolutely unforgivable relates to the recent tragedy in Creeslough.The Government pulled out counselling supports after one month and moved it online. That is unforgivable. It was the biggest national tragedy in ten years but those people are not being provided with ongoing counselling services.

The most vulnerable children in the country are those in care. When they leave child services, they get a few sessions every year on the adult services. That is not good enough. They need more. They might get ten sessions if they are lucky but some children need ongoing therapy, possibly for many years, right up to the age of 23. The Minister of State needs to consider that. Those children when they leave child services are not getting enough counselling support through adult services.

Mary Seery Kearney (Fine Gael)
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I thank Senator Keogan for taking the Chair and allowing me to contribute. The Minister of State's personal response on this issue and her work in this area have been extraordinary. I am very grateful to her and am a great admirer of her commitment and the compassion she shows in every interview to which I have listened, as well as in how she responded in the Dáil.

An important point to pull out of her speech is that the teams have triaged 21,000 referrals and 225,000 appointments have been delivered. Every one of those appointments is delivered by people who are incredibly committed and compassionate and absolute professionals in the delivery of services. It is important for parents to hear that because I know, as a parent, I panicked when I heard some of the recent revelations. It would be a frightening prospect for a Member of this House, let alone for those who do not have access to the sort of information we have, to consider what would happen if his or her child develops a psychosocial disability and requires a response to it, and where the State is going to be in that regard. In this context, it is important to remember that an awful lot of delivery happens exceptionally well all of the time.

However, we cannot speak about this and not have a "but" somewhere. The briefing we got from Mental Health Reform, which I am sure the Minister of State also received, as well as hearing about in the Dáil last night and in the statements, highlighted the things that are needed. It highlighted the acute areas and gaps. An issue that also comes up in other disability services is the lack of memorandums of understanding with the private sector. Why do we not fill the gaps more intentionally and accept private assessments and services? At the height of Covid, we were able to do that with private hospitals. This is an ongoing; it is not new. Why can we not move to fill the gaps while we recruit?

I accept the point made by the Minister of State in her remarks that there has been a 33% increase in demand and, in terms of cases, a 21% increase in a short period from 2020-21. In the context of Covid, that was probably understandable but perhaps it would have happened anyway because life is very different now, especially for young people. The pressures on them are completely different, so there is more potential for needing an assessment, whether it goes on to full service or not.

Within the service, there is inconsistency in the threshold for acceptance. I was contacted by the mother of an 11-year-old child who has a diagnosis of autism and an intellectual disability. They tried to access CAMHS via the local team and put together an in-depth application setting out the reasons they needed to access the service and proving that all other avenues, such as the use of therapy and engagement with the team, had been exhausted. The child is self-harming, suffers from chronic anxiety and exhibits behaviours like bashing his head off the wall, table, or bannister or kneeing himself in the face but CAMHS twice came back to the family saying he did not meet the criteria for mental health assessment. The family had to threaten CAMHS with the possibility of family breakdown and a requirement to find him a residential or foster placement but CAMHS still would not agree to see him. It has provided for four engagement sessions with the team only but not with the child. What is the threshold? Is it clear? It is clear that it is not consistent across the country. That comes out through the report and some of the commentary we received on it. At what point does a child trigger the necessary criteria to assure the provision of services? It appears that whether a child is accepted depends on who is doing the assessment. The email to which I referred is one of several I received in respect of children exhibiting similar behaviours and families that are desperately seeking help. We need clarity on this. I appreciate that is not something that can be done through a statutory instrument or whatever as it needs the engagement of professionals in the area. A review is certainly required.

We cannot have a two-tier system. We cannot have a system whereby parents detect a growing psychosocial issue with their child and then those who have the resources can go down a private route and get a response for the child, while those who do not have the resources experience fear in respect of whether their child is going to be treated. We need to address that. I appreciate all the work the Minister of State is doing and thank her for it.

Paul Gavan (Sinn Fein)
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The Minister of State is very welcome, as always. It is important that we are having this debate today. The report of the Mental Health Commission is another indictment of the state of medical services. It outlines familiar failings such as a lack of staffing and capacity. The author outlined five areas of particular concern, namely, shortage and high turnover of staff, a lack of capacity to provide needs-based therapeutic programmes, poor monitoring of medication, a lack of clinical governance and, finally, long waiting lists that are impacting the safety and well-being of children. The Minister of State will agree that mental health is as important as physical health and to see such concerns raised about the treatment of children and adolescents must be treated as a major concern by her and the Minister for Health, Deputy Donnelly.

The fact that there are 140 lost children in one CAMHS team alone is abhorrent. As the Minister of State is aware, the area in question is the mid-west, the area from which I come, covering counties Limerick, Tipperary and Clare. Children on medication not having a follow-up for two years is entirely unacceptable. It is inexcusable that some children on antipsychotic medications were not monitored. Whichever way the Minister of State frames it, this report is damning in terms of service failures. Its author, Dr. Susan Finnerty, put it aptly when she stated that she "decided to issue an interim report because of the serious concerns and consequent risks for some patients that we have found across areas of 4 out of 5 Community Healthcare CAMHS". Four out of five areas. This is not just one problematic team; it is a problem that spreads across nearly every area. Later in the report, referring to a particular CAMHS area, she stated "it was unclear at what stage these children would be re-assessed".

Maybe we should not be shocked. We already knew the Government had not provided enough resources to mental health and that, of that scant funding, only 10.8% of the mental health budget is assigned to CAMHS. It is clear this funding needs to be dramatically increased, as does spending on mental health more generally. CHO 3, which covers parts of the mid-west, including Limerick, has been under pressure for quite some time. That is evident from the percentage of referrals the team accepts. In 2019, of the 1,856 referrals it received, 75% were accepted. In the first half of 2022, only 65% of 849 referrals were accepted. The referrals that were accepted are then taking too long to be seen.

I have been dealing with a family with a child born in 2016 who was referred to CAMHS.One year after their referral, they have no appointment and have been advised they will be waiting another year. A child who was referred at six years of age will be nine by the time he gets seen. There is too much lost time and too many lost children.

There is a real lack of out-of-hours services and this is contributing to the overcrowding of our emergency departments. In November last year, 741 young people presented at emergency departments. In my county of Limerick I look forward to the long-awaited launch of the 24-7 mental health de-escalation unit. This will handle out-of-hours calls and triage and ensure that those with out-of-hours mental health concerns are directed to where they can receive the appropriate care. It is imperative that this team is staffed and resourced appropriately. If successful, this model must be rolled out throughout the State.

I urge the Minister of State to act on the interim report and take immediate actions to address the litany of failings in our child and adolescent mental health services. As a priority she must review all open cases and ensure that the so-called lost cases are offered support and a necessary, albeit belated, follow up. The Minister of State should ring-fence the budget for CAMHS and work towards the recruitment and retention of professionals in the field.

I will finish by making a few suggestions on what we believe should be done. Early intervention is key. All children and young people deserve the opportunity to reach their potential. Children and young people must have access to mental health services when and where they need them. Services should be extended to 25 years of age to prevent the cliff edge at 18. The majority of acute long-term mental health difficulties develop between the ages of 16 and 25. We are calling for multi-annual funding for CAMHS to be able to operate and forward plan to be able to staff teams properly. We are calling for integrated IT systems to improve quality of care. We want accountability in mental health services and so we are calling for a national clinical director for mental health, a role that was removed by the Minister, Deputy Harris, in 2016. I cannot stress enough the importance of accountability. It is at the heart of all the issues we are discussing today.

Sinn Féin wants to empower CAMHS to be able to respond to issues raised in the Mental Health Commission's interim report. That report did not come as a shock to any family with experience of accessing CAMHS. They know only too well that the Government has been failing young people as waiting lists have dramatically increased under its watch. We must introduce national standards for monitoring antipsychotic medication. We must develop a joined-up and comprehensive health and social care workforce strategy to increase education places and training opportunities between the Department of Health, the Department of Further and Higher Education, Research, Innovation and Science, the HSE, regional health areas, hospital groups and higher education institutions. We must increase undergraduate and postgraduate courses and training places for mental health professions based on evidence of required staffing levels and projected population needs to reduce reliance on overtime and international recruitment.

Our mental health services are in crisis and we can do much better. We owe it to our children and young people who deserve hope, solutions and mental health services that are fit for purpose.

Annie Hoey (Labour)
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I thank Mental Health Reform for all its advocacy and the support it provides. I have been contacted by people for whom CAMHS has let them down or has not been right. I have also been contacted by parents where it has worked for their child. The system can work for some people. Unfortunately, we are not here to talk about those people but we are here to talk about the people for whom the system has not worked and who have been let down by the system.

I am sure in the trials and tribulations of our job, all of us were contacted about CAMHS before the publication of this report. I remember one case that really stood out and did not make sense to me. It was a trans adolescent who had an eating disorder. CAMHS in their area said it could not help. There were multiple issues. We tried to help and do what we could. The parents sometimes wondered if they had been living in a different area whether the CAMHS in that area would have been able to help. I occasionally think of that young person who would now be nearly in adulthood and how they got lost in the system because they were too complex for the system. We cannot let people fall through the cracks because something is deemed too complex. They were in deep distress and in deep need and were let down in that area.

The Mental Health Commission's interim report into CAMHS is a damning indictment of the crisis in our mental health services. The report illustrated how disjointed and under-resourced CAMHS is and how a failure of clinical oversight is putting children's safety at risk. The report highlights the following: the dysfunctional system of long waiting lists; poor clinical governance; staffing problems; children who have got lost in the system; a lack of capacity to provide appropriate therapeutic interventions; and a lack of emergency CAMHS out-of-hours services. I will come back to the last piece in a minute.

There was evidence of some teams not monitoring antipsychotic medication. Mental Health Reform was deeply alarmed that some CAMHS teams are neglecting to monitor children who are using antipsychotic medication, which is very worrying. I am sure it is very frightening for parents to hear that their child might not be monitored on something like this. They were taking medication without appropriate blood tests. Physical monitoring is essential when on this medication. These practices could have some serious repercussions for children's and adolescents' physical and mental health both immediately and in the future.

In one particular CAMHS team there were 140 lost children. They were not literally lost but children who should have had follow-up appointments, including for review of prescriptions and monitoring of medication, but did not have an appointment. This happened as a result of paperwork or staff changeover. In addition, the Mental Health Commission stated it identified another team that had open cases of children where there was no documented review for up to 2 years. This risk had not been identified by this CAMHS service. Another team were attempting to identify an unknown number of cases that had been lost to follow-up following a change in staffing. Other teams had commenced a six-monthly review of their open cases following the Maskey Review.

Last week two presentations on digital patient records were made to the Joint Committee on Health. It was very clear at that meeting that we are not where we need to be in the introduction of electronic digital patient records. It is not acceptable for records to be lost because of staff turnover.

Obviously, we welcome the review of all open CAMHS cases, but further actions are required. The recruitment of a youth mental health assistant director was promised in the budget for 2023. As far as I am aware, recruitment has not yet begun on this.

Mary Butler (Waterford, Fianna Fail)
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It started yesterday.

Annie Hoey (Labour)
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It started yesterday. I wrote this speech yesterday morning so I can just scribble that right out and skip to the next page. It has begun in a timely and efficient manner.

There must be a reinstatement of the national director for mental health in the HSE who needs to report directly to the CEO of the HSE. The programme for Government contains a commitment to reinstate this position, but recruitment for this position is not where it needs to be. There has been no national director for mental health since 2016. I was president of USI in 2016, which feels like a lifetime ago. That is a long time for us not to have that national director.

We need to reform the Mental Health Act 2001 to ensure children's rights are protected when they access mental health services. Current legislation is significantly out of line with international human rights standards. As a matter of urgency the mental health (amendment) Bill needs to be progressed this year.

We cannot have a postcode lottery as to who gets services depending on where they live and the CAMHS service to which they are linked. That practice needs to end. I agree with a previous speaker that we need to extend the age. People going in aged 16 know they will not get seen before they are 18. Extending the age will prevent those young people falling between two stools. It is up to the Minister of State and her team along with the Minister for Health. We need to get things right for our children because if we cannot, what hope do we have?

Frances Black (Independent)
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The Minister of State, Deputy Butler, is very welcome to the Chamber. I thank her for coming to the Seanad to update us on the issues in this important debate. I agree with colleagues who have said that when CAMHS works, it works really well.I thank her also for her commitment. Nevertheless, the recent report of the Mental Health Commission regarding the state of CAMHS is truly alarming and very upsetting. I am grateful to Dr. Susan Finnerty and everyone else at the commission who worked on the report and brought this to our attention. I welcome Mr. Stephen Sheil from Mental Health Reform to the Gallery.

I spoke about this report in the Chamber last week, so I will try not to repeat myself. By now, we are familiar with the dire findings of the report and the hundreds of children lost in the system who went without follow-up, the children who were prescribed antipsychotic medication without proper medical monitoring, and the chaotic record-keeping and case management procedures that are exacerbating a crisis caused by persistent staffing shortages and chronic failures in governance. It paints an unbelievably grim picture. Imagine how you would feel if it were your child. It is devastating to think your child would not get the services he or she needs.

This crisis is severely damaging to the welfare and safety of some of Ireland's most vulnerable children. It puts a great strain on families and caregivers. As colleagues said, 741 children with mental health difficulties ended up in emergency departments for days because they were experiencing an acute crisis. Let us think about that. That they could not find help elsewhere is devastating. It is also very stressful and demoralising for the healthcare workers, who have to spend their professional lives working within a dysfunctional system, dealing with people who are at their wits' end with the stress and worry. These workers are drained, not only by the inherently difficult and emotionally intense nature of their work but also because they have to apologise to young people and their families on behalf of a broken system they lack the power to change. My concern is that the dysfunction of CAMHS has become almost a self-fulfilling prophecy. It is impossible to recruit and retain the necessary staffing levels when frustrated and burnt-out workers keep leaving due to the problems created by the understaffing.

CAMHS needs a significant overhaul, including ring-fenced funding, which other Senators raised, a minimum safe staffing level and enhanced accountability mechanisms. There needs to be an holistic approach to this issue, including more college places for CAMHS professionals and competitive salaries that reflect the difficulty of the work involved and the high cost of living in many parts of Ireland, particularly Dublin. The report notes the issues faced at the level of clinical leadership due to the shortage of consultant psychiatrists. The description of how scarce these professionals are throughout the CAMHS system is truly alarming and I hope it will serve as a wake-up call that the recruitment and retention of these consultants is vital.

This shortage could, however, provide an opportunity to explore further a shared responsibility model of multidisciplinary team leadership, something the Minister of State is passionate about. This would be in line with the holistic person-centred model of care envisioned in the Sharing the Vision strategy. Ireland has just been reviewed in Geneva regarding its compliance with its obligations under the UN Convention on the Rights of the Child and this report indicates we have a long way to go towards vindicating the rights of children with mental health issues to get the highest quality healthcare. It is unfortunate there has been a lack of progress in this area. There were 32 admissions of children to adult mental health units in 2021, up from 27 in 2020, but when the UN committee asked the Government when the number of children admitted to adult mental health units would be reduced to zero, the response, unfortunately, was that Ireland may never reach that goal. This shows a distinct lack of ambition to adhere to international human rights standards, which is deeply troubling.

I would love to hear more about the recruitment of a youth mental health assistant director being made a priority. That is very good news and I am happy to hear about it.

The Oireachtas Sub-Committee on Mental Health, which I chair, recently conducted pre-legislative scrutiny on heads of a Bill to amend the Mental Health Act, and this report underscores the vital need for the reform of that Act to proceed swiftly. It also highlights the need for provisions in the revised Mental Health Act to codify children's rights and ensure the provision of CAMHS will be shaped at every stage by the principles of care, dignity and security, which underpin children's rights under the convention. The subcommittee will have representatives from the HSE in within the next fortnight to discuss this report, and I look forward to hearing from them what actions they will take to rectify the issues raised in the report.

This crisis in CAMHS demonstrates how much work needs to be done in the mental health sphere, and I appreciate the Minister of State knows that. For too long, it has not had parity with physical health and that disparity can be seen throughout the system. There are the beginnings of a societal and political understanding of the need for change, but we have a long way to go, and in the spirit of parity between physical and mental health, the Sub-Committee on Mental Health should be given the resources necessary to be an independent committee. I have spoken to the Minister of State about this previously and acknowledge she is supportive of it. I thank her for that and hope we can build on that support.

A society's worth should be judged by its treatment of its most vulnerable members. If Ireland cannot provide a dignified standard of mental healthcare to our children who are suffering, it makes all the talk of economic growth, budget surpluses and the corporation tax take seem delusional and pointless. It needs to be made a priority because our children deserve so much more.

Mary Seery Kearney (Fine Gael)
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Before we go to Senator Conway, I welcome the group in the Gallery from St. Christopher's Services, including both users and staff members, who are visiting with Deputy Flaherty. They are all very welcome and I thank them for joining us.

Martin Conway (Fine Gael)
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I join the Acting Chairperson in welcoming the group from St. Christopher's Services, a great facility in County Longford.

I welcome also the Minister of State. This is a difficult and challenging subject and she is dealing with decades of underfunding. Trying to scale up quickly is a big challenge. When the report was published last year regarding the situation in Kerry, we were all quite shocked and appalled. The correct decision was made at the time, following on from the report, to examine the situation in the other areas and groups and to provide that an interim report would have to be published after work was carried out by a number of those groups. It is disappointing to think the nuts and bolts within the services were so poor that they were really only cobbled together and that they are not something we can stand over as a modern, effective, compassionate, caring and supportive CAMHS. Nevertheless, we have to start somewhere, and the level of investment that has been put into the services is unprecedented.

What was revealed in the most recent report, especially in the mid-west, where there was a description of 140 people as "lost children", was horrifically upsetting to hear, but the actions being taken to engage with the families of those 140 children are a step in the correct direction, even if it should truly never have happened. We need a system that is properly fool-proofed whereby that kind of thing will never happen again.

Another issue of concern to me, and it is one that is happening and has happened, relates to the idea of engaging with people over Zoom or by other means online. A young person cannot be properly assessed online. There has to be face-to-face contact. I do not think anybody would have confidence that tele-supports such as that are appropriate. That is not how we want to do business and I would certainly not be happy to stand over it. I hope that will come to an end. We have seen the interim report, and I dread what is going to be in the final report. Whatever it is, we will have to take it, deal with it and build capacity. Clearly, the funding is there, but there is a serious problem with retaining professionals. I do not know how we should deal with the lack of availability of professionals, whereby positions that are being advertised are not even being applied for. Perhaps we need to reconsider the terms and conditions that are on offer, because if they are attractive enough, people will apply.I am sure that many of the professionals from this country who have moved abroad would, under the right circumstances, consider coming back to Ireland. We need to think outside the box. Where we need to have new remuneration for specific posts, it should be considered. It is frustrating that advertisements are published to hire the necessary professionals and very few people, if any, apply. One must ask what the problem is.

In respect of what is available from universities and colleges, a job of work can be done with the Minister for Further and Higher Education, Research, Innovation and Science to see can we come up with new programmes to encourage more young people to go into caring professions and qualify. That is a challenge across the healthcare sector but it is a particular challenge in this area. The Joint Sub-Committee on Mental Health will be doing a deep dive into the issue. Perhaps the Minister of State will come before it to allow for a more intimate question-and-answer session over a period. I again commend the Minister of State on her genuine commitment to trying to improve the lives of young people in this country.

Lynn Ruane (Independent)
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I welcome the Minister of State to the House. This is an important conversation but it feels like it is just a conversation. I do not feel urgency in the room. It all feels a bit nice. We are talking about the lives of people and children. I do not know if the Minister of State has experience of communities with a high concentration of young people with severe mental health issues who are trying to access CAMHS. In west Tallaght, in particular, it is extremely difficult. We spoke earlier about numbers and triage. In that triage space, people are being told that the service is not for them. Women in my community wince if they are referred to CAMHS. They think they cannot go near CAMHS because there is no point and no one will see them. That is the culture that exists now. CAMHS is not understood as a place where people feel they are going to get support and help. They do not even feel they will get through the door. When one gets past the triage space and into the service, it is great. However, the barrier that exists makes it too difficult for people who are trying to get through the door. There are girls in Tallaght, especially teenagers, who are self-harming to bits. Their bodies are in bits when they arrive at CAMHS. They are told they are not suicidal enough. If they are not experiencing suicidal ideation, they are told the service is not for them. There is something seriously wrong if that is the measurement of mental health. You should not have to be almost about to take your life before being allowed access to the service. That needs to be rapidly reconsidered. That lack of service will lead to suicidal ideation and these people will not be in a service that can deal with it when that happens.

There is a also massive problem in respect of the transition to adult mental health services. Getting an assessment at an adult mental health service is extremely difficult unless a patient is presenting with psychosis or suicidal ideation. I agree what has been said by others about 18- to 25-year-olds. It would match with youth work strategies. We all acknowledge that young people are defined arbitrarily as being under 18. The transition piece is important. The target at the moment is six months but referrals cannot be given while a child is under 18. That means patients must wait until they turn 18 before a referral is made. They are dropping off the system as they try to access services.

Many other Senators have spoken about medication. Children are being lost and it feels as if nobody is taking responsibility. It feels like it is considered a nice phrase that these children have been somehow lost in the system. They just got lost. It is the result of complete negligence. It is neglect on the part of a State service not to know who is on medication and who needs follow-up. Some children were given a prescription for two years without any review by anybody. Other places recommend that patients go into the likes of Linn Dara to be observed while they move onto some of these medications because they can be serious. Those medicines may have psychoactive properties and relate to psychosis, even if they are used for many other things. Some psychologists will only prescribe some medications if a patient enters Linn Dara for a period of time to monitor the effects. That is how serious a matter this is. The fact that many children were not monitored at home and did not have their prescriptions reviewed is neglect.

There is also a postcode lottery. Only two out of five CAMHS are capable of dealing with eating disorders. Four of five can cater for intellectual disabilities. Only one can cater for ADHD. Considerable numbers of young people in the prison system with ADHD also have comorbid mental health issues because they did not receive care. The shortcomings in care spring over to the justice system, antisocial behaviour and everything else. People with ADHD need support at a younger age to allow for interventions. The numbers of people with ADHD who do not receive support and who then engage with the justice system is concerning.

Integrated care and needs-based wraparound services do not exist. According to the interim CAMHS report, there is a blame game among service providers about which organisation should accept referrals to services for treatment. Families are bounced back and forth from CAMHS to other primary care and disability services. However, a child or young person cannot be on multiple waiting lists. They must cautiously seek help, knowing that an upcoming appointment with a primary care service could remove them from the CAMHS waiting list. That a child cannot be on two waiting lists at once makes me wonder at the logic of decisions being made around people's access to support.

This report is savage. I have been working in the area of health equity in the community for years. In my lifetime, I cannot remember a time when we had a functioning CAMHS. I do not know when that existed. When we say CAMHS is in crisis, do we need to acknowledge that a functional and accessible service has never existed under our current model? The interim report reflected the concerns of the Mental Health Commission around the risk posed to children, risks which the HSE claims to have heard nothing about and has no record of, possibly due to a lack of infrastructure or IT services. The blame lies with the health services and the Departments. We need to stand over the report and aggressively address these issues because at the end of the day, children are dying. We may not have statistics for that now because deaths may not be associated with the fact that a young person did not receive an appointment. It is hard to do that. However, there are people who presented with self-harm or eating disorders for many years, did not get the support they needed and are now dead. We need to accept that is neglect on the behalf of the State.

Maria Byrne (Fine Gael)
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I thank the Minister of State for coming to the House to discuss this important topic. I acknowledge the fact that the report would not be out there without the Minister of State asking for it. I acknowledge that and the work she has done. I know she has an interest in the area.

My concerns regard CHO 3. The Minister of State would not expect anything else from me. The report on CHO 3 was the most damaging of the lot. Some 140 children were concerned. I hope they have all been contacted and I believe they have. A number of families contacted me about children who were 17 or 18 and still in school. We kept being told that those children were in the system and would be contacted. My understanding is those families were only contacted very recently. Two of those children are now over 18. That is frightening.

Children have to be able to access services. I know that some children receive many follow-up calls and might be seen at a clinic. However, if they need to be admitted for one reason or another, they must access adult services because there is nowhere for children in the CHO 3 region.It was a shock for their families to receive the report and hear highlighted in the news the stories of people being oversubscribed with medication. I know from speaking to some of the families that they experienced this horrific set of circumstances. I acknowledge that so many who work in the services do a very good job and are very responsive.

I apologise for not being here for the Minister of State’s opening statement; I was at a committee meeting. Perhaps she could highlight some of the responses to date and the current position. When will we expect to see the proposed resolutions to some of the issues highlighted, certainly by the families and especially regarding CHO 3?

Some people I know would benefit from a telephone call or from seeing the doctor in person. How long are the waiting lists in CHO 3? Perhaps the Minister of State cannot answer that today but perhaps she can revert to me on it. Is there a plan to have a CAMHS unit in the mid-west that people can access? Some have to go to Cork and others to Dublin. I thank the Minister of State.

Aisling Dolan (Fine Gael)
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The Minister of State is very welcome. Along with Senator Black, I am on the sub-committee on mental health. It is important to be really clear about what CAMHS does. It was outlined in the report that the services provide assessments and treatment for young people up to 18 years of age. The report goes through the various conditions treated. Included are depression, problems with food and eating, self-harm, psychosis, bipolar disorder, schizophrenia and anxiety. The report speaks to some of the agencies and groups that support CAMHS. It is quite difficult to read. I realise it has not covered all the CHO areas. It refers very much to children. One hundred and forty files have been lost in the system for two years. This is really hard to hear. It is very difficult to see what the children, their parents and families are going through but I appreciate that the Minister of State is obtaining the information to develop and implement a very rapid response.

Five out of the nine CHOs have been reviewed. My area covers Galway, Roscommon and Mayo, which are in CHO 2. The team there has been in touch with us. Early last year, it gave us an update. I will be looking for another update now. Self-harm and eating disorders are such an issue, particularly for young people. When will the final report be issued? The report we have is an interim report.

The Minister of State mentioned in her opening statement that over 80 psychiatrists are working in this area. I have a question on the recruitment and retention of psychiatrists dealing with the workload in question. What telehealth or e-health supports are being made available? This is a huge area. Even in respect of initial engagement, there should be so many opportunities in terms of telehealth. What innovations is the Minister of State considering? So much funding is put into e-health. What is happening is very frustrating for most of those who work in and use the service. I am sure the Minister of State has similar thoughts on that.

Another role of mine involves the education committee. We brought out the report on mental health supports for children in schools and at third level, in tertiary education. There were a number of recommendations. One, which I called for last week with Deputy Dillon and through Fine Gael, concerned the Youth Mental Health Pathfinder project. The Minister of State spoke about this recently in the Dáil and said there are so many Departments involved. Which Department is taking the lead? Is the Minister of State taking the lead in driving projects like this? She mentioned she is working with several Departments on this. Who is taking the lead? Is any progress being made? It could really make a difference.

Our schools and colleges are seeking to provide supports to young people. This report follows on from a report on bullying, including cyberbullying, produced by the education committee. Again, the findings on the impact of cyberbullying on young people were really shocking. It all leads to different types of mental health issues, including anxiety, stress, withdrawal and self-harm. It is amazing how all these are so tied together. The bullying report came out a year and half ago. With regard to supports available through the FUSE programme and engagement with schools, schools are crying out for counselling supports. Qualified counsellors themselves feel they are not qualified. An article in The Irish Timesyesterday referred to the impact of bullying and described how to identify the symptoms. This does not relate solely to CAMHS, but the society and culture we live in have so many impacts on young people. If the Minister of State could comment on any of these points, I would really appreciate it. I thank her for her time.

Mary Butler (Waterford, Fianna Fail)
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I thank everyone for being here for this debate. I appreciate the attendance of everyone who sat through the entire debate. I always look forward to coming into the Seanad to listen to the various contributions.

I will try to answer as many of the questions asked as I can. It is important to note that significant investment has taken place in community organisations that provide vital early-intervention services for children. While €125 million was spent on CAMHS last year, an awful lot more money is provided from my budget. Jigsaw, for example, was funded with approximately €12 million in 2022. It provides essential early-intervention supports for children and young people aged between 12 and 25. It had more than 2,600 appointments last year and 85 mental health workshops. Along with funding Jigsaw, we also fund MyMind. A sum of €1 million was provided last year to continue to deliver free-of-charge counselling sessions to clients in over 14 different languages. It is important to recognise that there are many who do not speak Irish or English and that we ensure they are catered for. I thank Mental Health Reform for its continuing advocacy. I also fund that through my budget so it will be able to hold me to account and inform everyone of the challenges we have. There are many.

There are a couple of points I want to make. Evidence shows that only 2% of children will need the support of CAMHS specialist services, with the majority of mental health supports for children and young people delivered through the communities. That is why I fund the communities through the budget. A further €1 million was provided through Mental Health Ireland for community and voluntary agencies last year.

I had a meeting last week with the consultant psychiatrist to tease out an issue raised quite a lot, which I have asked about myself. I am referring to the level of referral across the various CHOs. The rate is as low as 38% in some areas and as high as 81% in others. I was informed that a decision is not made by just one person. When a child is referred – by a GP, for example – the multidisciplinary team considers all aspects of his or her referral. In many cases, the child will be assessed and the multidisciplinary team will determine whether he or she meets the criteria. Many parents contact me and believe their child should be in CAMHS but I say I am not a medical person and do not have a clinical background and therefore must put my faith in the fact that the consultant psychiatrist and multidisciplinary team, working with the psychologist, dietician, occupational therapist and mental health nurse, make the determination. However, I am concerned that the rate varies widely, from as low as 38% in some CHOs to as high as 81% in others.

Five CHOs were examined: CHOs 3, 4, 5, 6 and 7. It has to be recognised that there were no issues raised in one CHO. If that is the case, it shows it can be done. There was a lot of talk about CHO 3 in respect of 140 lost files to be followed up. CHO 3 informed the Mental Health Commission in March that it had 140 files that had not been followed up for quite a while.I am always open to correction on this but my understanding is that a medical consultant had left the practice and only three and a half posts had been in place. This figure has increased to seven. This is the reason. The team itself was proactive and informed the Mental Health Commission that 140 files had not been followed up. They have been followed up since. I know the staff were not place immediately to do this but it has happened since. It is positive that they have been followed up.

Across the other three CHOs, a further 28 files were still open. At this stage, they have all been followed up on. I have requested, as has the Mental Health Commission, that all open files be examined. Last week I met Dr. Colm Henry, Mr. Damien McCallion and Ms Yvonne O'Neill from the HSE. They will look at all open files. Open files are those where the child or young person has not been seen in the previous six months. Approximately 3,500 files must be looked at. This is the estimate for the entire country. When I speak about doing a review of CAMHS, I want it done across all 73 teams. This is the only means by which I can find out what the picture is on the ground.

I spoke about the acceptance rates. These which tie in with the postcode lottery. Something I have been doing since I became a Minister of State two and a half years ago is funding the clinical programmes. When I came into the post, there was funding for three eating disorder teams. There is now funding for nine. It takes 12 to 18 months to put in place a multidisciplinary team. We almost have six going and another three are funded. By the end of this year, all nine should be in place.

Mention was made of ADHD. It is very important to point out that 40% of referrals to CAMHS are for children with ADHD. The report refers on page 20 to medication management and states that it was pleasing to note that in the majority of the sample of the files reviewed, physical monitoring was completed for children and young people with ADHD on stimulant medication. This has to be acknowledged. I have to look at the report in the round. I was very concerned about many issues and I have escalated them to the highest level to which they can go. At the same time, my main concern when I asked for the reports and audits to be put in place was coming off the back of overprescribing in Kerry. The evidence is that in 40% of ADHD cases physical monitoring has been done. This was not the case when I received the previous report.

The report also states that CAMHS staff work extremely hard to try to provide a good service. We are aware that many young people and their families have received excellent care and treatment. Many teams are innovative in trying to mitigate the risks posed by the lack of staff. I recognise this. Another discussion I had with the HSE last week was on looking at the teams that are under-resourced as against some of the teams that are well resourced. It is a bit of a postcode lottery and we are putting a focus on it. I was very concerned about mention in the report that in some cases there was no documental review for two years. This is simply not acceptable. I have zero tolerance of this.

I want to touch briefly on admission to adult wards. I spoke about this earlier. Last year, there were 19 cases where young people had to be admitted to adult wards. There are some instances where it happens with the best will in the world. I will speak about a case where a 17-and-a-half-year-old male was admitted to a psychiatric ward in Donegal on one particular night. A bed was found for him in Merlin Park in Galway. The person was extremely upset. A decision was made that for his own safety the best thing to do would be to move him in the morning after he had slept. Sometimes decisions are taken in the best interests of the health and well-being of the person by a medical practitioner who is way more qualified than me to support that young person.

I know we have been accused breaking various laws on this. My worry is whether I could stand here as Minister of State if a 17-year-old or a 17-and-a-half-year-old person was denied access to a department of psychiatry in an adult unit if nowhere else was available and that young person left the facility and the outcome was death. This is why I have to try to weigh it up. I do not ever want to see a young child in an adult psychiatric facility but there are occasions when we must balance the risk and I have to be conscious of this. There is a risk there. Thankfully, the people involved in the 19 cases last year were all aged 16 and 17.

I have spent a long time discussing this matter with consultant psychiatrists. No consultant psychiatrist wants to put a young child in an adult facility. I have to say that when they are in an adult facility they are monitored 24-7. Somebody sits outside the door looking through the glass window. This happens. This is the one thing I want to say about it. There is balance of risk. There is a little bit of a grey area and it is done on a case-by-case basis. There will never be a situation when we will have acute inpatient services for children in every county in Ireland. This just will not happen. It would be remiss of me not to say this.

A key recommendation of the Maskey report was that we would look at online supports to see what we could to. At present we are using it in Kerry with a doctor who worked previously in Ireland. I will make several points to allay the fears of Senator Conway. Every young child the doctor has diagnosed he has seen in person. He flies in and sees them in person. After the diagnosis has been made he sees the child online. That child is not in his or her bedroom or sitting at home. That child is in the CAMHS unit in Kerry. A member of the multidisciplinary team is sitting beside them. We have been told to be innovative and to look outside the box. We have a fantastic e-mental health hub in Roscommon. It used to be the old Rosalie facility. I visited there with the then Minister of State Deputy Feighan. It gets support from the CAMHS team and the inpatient team in Galway. It does work. There is funding in the budget to roll out two more of these. This year €6 million has been provided. We have to think outside the box in respect of issues such as this.

I know I have gone over time, but I have one more point to make. We are looking at age limits. Reaching 18 is a very difficult time in the lives of young people. They might be doing the leaving certificate or going to college. They might have been receiving the support of an eating disorder team for four years and then they reach a cliff edge. A sub-committee of the national implementation and monitoring committee has been formed to look at best practice, and whether services should continue to the age of 21, 23 or 25 years. I am open to persuasion on all of this. I certainly believe that at a minimum it should be extended to the age of 21. Jigsaw works for those aged between 12 and 25 years and it works very well. I am open to persuasion regarding age. I want to urge a note of caution. This will work very well in the community services but it will not work in the same way in inpatient services. We cannot have a situation where we have a 12-year-old girl who weighs five or six stone and who has an eating disorder positioned beside a young man of 21 who is psychotic. For community services, it could work very well . However, there would have to be a lot of work and research done on inpatient services.

I thank Senator Black for all the work she does with her committee. I fully support her call for a stand-alone mental health committee. I am happy to come before the Seanad, the committee and the Dáil. The more we speak about mental health and the resources we need, the better. I have been very taken today with the number of constructive recommendations that have been made. Everybody wants to see a better service, and I thank the Senators for this. I thank the Acting Chair for her indulgence.