Seanad Éireann - Volume 179 - 17 February, 2005
Mental Health Commission Annual Report 2003: Statements.
Mr. T. O’Malley Mr. T. O’Malley
 Mr. T. O’Malley: I welcome this opportunity to make a statement in the House concerning the second annual report of the Mental Health Commission. This report relates to the year 2003. The Mental Health Commission was established in April 2002 under the provisions of the Mental Health Act 2001. The Act is a most significant piece of legislation and its purpose is twofold. First, it provides a modern framework within which people who are mentally disordered and who need treatment or protection, either in their own interest or in the interest of others, can be cared for and treated. In this regard, the Act brings our legislation in respect of the detention of mentally disordered patients into conformity with the European Convention on the Protection of Human Rights and Fundamental Freedoms.
The second purpose of the Act is to put in place mechanisms by which the standards of care and treatment in our mental health services can be monitored, inspected and regulated. The Mental Health Commission is the main vehicle for the implementation of the provisions of the Mental Health Act 2001. The commission has 13 members, including a practising barrister, two registered medical practitioners, two consultant psychiatrists, two representatives of the nursing profession, a social worker, a psychologist, a representative of the general public and three representatives of voluntary bodies promoting the interest of people suffering from mental illness, of whom two have themselves suffered mental illness in the past.
The commission is chaired by Dr. John Owens, former clinical director of mental health services in Cavan-Monaghan. The commission appointed Ms Bríd Clarke to the position of chief executive officer in 2002 and a full complement of 23 staff has been recruited and appointed since then. Directors have been appointed to head the two main divisions, one dealing with standards and quality and the other with tribunals. Under the provisions of the Mental Health Act 2001, the previous office of the Inspector of Mental Hospitals has been replaced with the office of the Inspector of Mental Health Services. Dr. Teresa Carey has been appointed to the position of Inspector of Mental Health Services and together with her team of assistant inspectors has commenced a programme of inspections of mental health services. The commission has also acquired and refurbished suitable premises and now operates from St. Martin’s House, Waterloo Road. As I have indicated, one of the principal responsibilities of the Mental Health Commission is to promote and foster high standards and good practice in the delivery of mental health services.
The Mental Health Act 2001 requires the Inspector of Mental Health Services to visit and inspect every approved centre each year and to visit and inspect any other premises where mental health services are being provided, as the inspec tor believes appropriate. This includes community residences and day centres as well as acute inpatient facilities. The inspector is then required to carry out a review of mental health services in the State and furnish a report in writing to the Mental Health Commission. The inspector’s review of the services, including reports of inspections carried out, is published along with the Mental Health Commission’s annual report and is laid before both Houses of the Oireachtas. The inspector’s annual report, which is before us today, informs the commission, the Minister for Health and Children and all interested parties on the current state of affairs within the mental health services.
The annual report of the Mental Health Commission for 2003 includes for the first time the report of the new inspector. This report, unlike future reports from the Inspector of Mental Health Services, does not incorporate reports on mental health services inspected in 2003. These inspections were completed by the former Inspector of Mental Hospitals and were published separately.
The aim of Dr. Carey’s more limited report for 2003, her first year in office, is to inform the commission on the role of the inspectorate and how it plans to carry out its duties. Dr. Carey indicates she will prioritise inspection of service delivery rather than inspection of structures, as the availability of resources and the way in which resources are used have a major impact on service quality. To this end, the inspector intends meeting service managers and providers to discuss and jointly evaluate local services. The inspector will obtain the perspective of general practitioners, local gardaí and other referring agents. She also indicates her intention to develop ways of ensuring that the views of service users and providers are sought and recognised.
In her report Dr. Carey sets out her intention of working closely with the Mental Health Commission to ensure the commission’s priorities and policies are reflected in the inspection process. This will allow the commission to be fully informed about issues of quality in service delivery and will facilitate the commission in its statutory obligation to promote high standards and good practice in the delivery of mental health care.
Dr. Carey’s first report highlights current issues within the mental health service, trends in mental health service delivery and the inspectorate’s views on priority areas which need to be addressed in modernising mental health services. She refers to the 1984 document, Planning for the Future, which recommended the establishment of a comprehensive, community-orientated mental health service as an alternative to institutional care for persons with mental illness. A shift from a predominantly hospital-based service to a service delivered to patients with the least disruption to their daily lives in the community has taken place in recent years with significant improvements in standards of patient care.
 In recent years there have been dramatic changes in both the concept and practice of mental health care delivery. Major strides have been and continue to be made in developing a comprehensive, community-based service which is integrated with other health services. I am fully committed to furthering the process of providing community-based facilities. Under the national development plan significant capital funding has been made available to the mental health services. A major part of this funding has gone towards the development of acute psychiatric units linked to general hospitals as a replacement of services previously provided in psychiatric hospitals. In addition to the 22 acute units in place, a number of units are at various stages of development. In 2003 new acute psychiatric units opened in Kilkenny and Castlebar. In 2004 a new unit opened in Portlaoise and two more such units at Connolly Hospital, Blanchardstown, and St. Vincent’s Hospital, Elm Park, are expected to open in the near future.
The plan also provides for more community facilities. Services have been developed towards creating a modern, comprehensive community-based mental health service. This has resulted in a continuing decline in the number of inpatients with a corresponding increase in the provision of a range of care facilities based in the community to complement inpatient services. Approximately 418 community psychiatric residences provide more than 3,210 places. This compares with 391 residences providing 2,878 places in 1997. These developments have resulted in a continuing decline in the number of inpatients. In December 1984, there were 12,484 patients in psychiatric hospitals and units, compared to 3,701 at 31 December 2003.
However, I accept that, as Dr. Carey points out in her report, much remains to be done. I am committed to providing quality care in the area of mental health, upholding the civil and human rights of those who suffer from mental illness and encouraging measures aimed at combating the stigma often associated with such illness. During my term of office as Minister of State with special responsibility for mental health, I am endeavouring to continue to accelerate the growth in more appropriate care facilities for people with a mental illness through the further development of community-based facilities throughout the country.
The annual revenue expenditure on our mental health services reached €725 million in the 2005 Estimate. This has allowed for the development and enhancement of multidisciplinary teams in the areas of child and adolescent psychiatry, psychiatry of later life, liaison psychiatry, rehabilitation psychiatry and suicide prevention programmes and support for the voluntary sector. An additional €15 million revenue funding has been made available for the further development of mental health services in 2005.
The inspector refers to the continuing need to develop specialist psychiatric services. The need  for these services has been recognised for some time and substantial progress has been made in putting these services in place. With regard to child and adolescent psychiatric services it was accepted that, with the increasing pressures on young people, there was a need to improve responses to their mental health needs. A working group was established by the Minister for Health and Children in June 2000 to examine the state of child and adolescent psychiatric services, carry out a needs analysis of the population aged under 18 years for such services, identify shortcomings in meeting such needs and make recommendations on how child and adolescent psychiatric services should be developed in the short, medium and long term to meet identified needs.
The development of child and adolescent psychiatric services has been a priority in recent years. Since 1997 additional funding of almost €19 million has been provided to allow for the appointment of additional consultants in child and adolescent psychiatry for the enhancement of existing consultant-led multidisciplinary teams and towards the establishment of further teams. This has resulted in the funding of a further 19 child and adolescent consultant psychiatrists. Nationally, there are now 52 such psychiatrists employed.
The first report of the working group on child and adolescent psychiatry published in March 2001 recommended the enhancement and expansion of the overall child and adolescent psychiatric service as the most effective means of providing the required services. The working group found that internationally acknowledged best practice for the provision of child and adolescent psychiatric services is through the multidisciplinary team. It noted that many of the child and adolescent psychiatric teams currently in place throughout the country do not have the full complement of team members required and recommended that priority should be given, in the first instance, to the recruitment of the required expertise for the completion of existing teams.
The first report also recommended that a total of seven child and adolescent inpatient psychiatric units for children ranging from six to 16 years should be developed throughout the country. At present, inpatient services for children and adolescents under 16 years are provided in two locations, Warrenstown House, Dublin, and St. Anne’s in Galway. Project teams have been established for four such units in Cork, Limerick, Galway and one in the Eastern Regional Health Authority area at St. Vincent’s Hospital, Fairview. Approval was recently given to tender for design teams for the projects in Cork, Limerick and Galway.
The second report of the working group on child and adolescent psychiatry was presented to me at the Department of Health and Children on 10 June 2003. This report contains proposals for the development of psychiatric services for 16 to 18 year olds. It recommends that, in the further  development of the child and adolescent psychiatric service, priority should be given to the recruitment in each health board area of a consultant child and adolescent psychiatrist with a special interest in the psychiatric disorders of later adolescence.
The working group’s report further recommends that arrangements should be made with the relevant adult psychiatric services for the admission to acute psychiatric units of persons aged 16 to 18, under the care of the consultant child and adolescent psychiatrist with a special interest in the psychiatric disorders of later adolescence, where such a consultant is available. The report emphasises the importance of co-operation and close liaison between child and adolescent psychiatry and adult mental health services and suggests that the current arrangements, whereby the adult services serve the population of their catchment are, including the 16 to 18 age cohort, should continue on an interim basis.
There is widespread concern at the rise in suicide rates in Ireland. Undoubtedly, suicide is a serious social problem in this country. There were 444 deaths from suicide in 2003. The high incidence of suicide is not confined to Ireland but is a growing global problem. Apart from the increase in the overall rate of suicide in Ireland, a disturbing feature is the significant rise in the male suicide rate, in particular that of young men. These worrying trends require further research so that better strategies are developed to help people who are particularly at risk.
Since the publication of the report of the national task force on suicide in 1998, there has been a positive and committed response among both the statutory and voluntary sectors towards finding ways of tackling this tragic problem. A suicide research group has been established by the chief executive officers of the health boards. Resource officers were appointed in all health boards with specific responsibility for implementing the task force’s recommendations.
The level of funding being provided for suicide prevention is now more than 20 times greater than in 1999. A cumulative total of more than €17.5 million has been provided towards suicide prevention and research. The health strategy, Quality and Fairness — A Health System for You, includes a commitment to intensify the existing suicide prevention programmes in future. Work on the preparation of a national action oriented strategy for suicide prevention is now well under way. The proposed strategy, which will involve the Health Service Executive, the national suicide review group and the Department of Health and Children will be action based from the outset and will build on existing policy. All measures aimed at reducing the number of deaths by suicide will be considered in the preparation of the strategy, which will be completed later this year.
 The Mental Health Commission and the Inspector of Mental Health Services operate independently of the Minister for Health and Children and the Department. The inspector, as an independent office holder, has a crucial role to play in providing an accurate and detailed account of services in the mental health sector throughout the country. This independent status is crucial to the advancement of the agenda for change and modernisation in the mental health services in the coming years.
The inspector has indicated in her 2003 report that the work of the Mental Health Commission is closely linked to her own, particularly in the areas of standards and quality. The Mental Health Commission will maintain a register of approved centres in which each hospital or inpatient facility providing psychiatric care and treatment must be entered. The Minister will make regulations specifying the standards to be maintained in all approved centres, including requirements pertaining to food and accommodation, care and welfare of patients, suitability of staff and the keeping of records. The Mental Health Commission will be responsible for the execution and enforcement of these regulations through the work of the new Inspector of Mental Health Services.
As well as working to ensure high standards and good practices within the mental health services, the Mental Health Commission has a second significant function. One of the key provisions of the Mental Health Act 2001 is that each decision by a consultant psychiatrist to detain a person involuntarily for psychiatric care and treatment will be reviewed. This review will be carried out under the aegis of the Mental Health Commission. The review will be independent, automatic and must be completed, except in certain circumstances, within 21 days of a person’s detention. The process will begin immediately on a person’s admission. All patients will have a right to review, even if they are discharged before 21 days have elapsed and the Act provides that they must be so informed when they are discharged. Reviews will be carried out by one or more mental health tribunals, consisting of a consultant psychiatrist, a lawyer and a lay person operating under the aegis of the Mental Health Commission. As part of the review process, the mental health tribunal will arrange, on behalf of the detained person, for an independent assessment by a consultant psychiatrist. The commission will also provide free legal representation to each person whose detention is being reviewed. The review of detention will be substantive and will focus on whether the person concerned is mentally disordered and whether the correct procedures were carried out in his or her detention. A tribunal will be empowered to order the release of a patient if it considers involuntary detention to be unnecessary.
The Mental Health Commission’s strategic plan 2004-05 indicates that one of the commission’s priorities for the coming year is to  create the structures required for the operation of the tribunals. The commission’s officials are working with the Health Service Executive, my Department and all stakeholders to ensure these structures are in place as soon as possible.
This House might be aware that I established an expert group on mental health policy in 2003 to prepare a national policy framework for the further modernisation of the mental health services, updating the 1984 policy document, Planning for the Future. The terms of reference for the group are to prepare a comprehensive mental health policy framework for the next ten years, to recommend how the services might best be organised and delivered and to indicate the potential cost of the recommendations.
The expert group will address many of the issues highlighted by Dr. Carey’s report. The group consists of 18 widely experienced people who are serving in their personal capacity. The membership encompasses a wide range of knowledge and a balance of views on many issues affecting the performance and delivery of care in our mental health services. Dr. John Owens, chairperson of the Mental Health Commission is a member of the expert group and Dr. Carey herself works as a member of one of its subgroups.
The expert group has consulted widely in its work. Submissions were invited from interested organisations, individuals and the public in October 2003 and 150 submissions were received. These submissions are now being considered by the group and further consultative initiatives with various stakeholders have been undertaken. The views of many service users were obtained from a questionnaire issued through the service providers.
The consultation process consisted of written submissions, questionnaires, two public consultation days and one-to-one consultations with service users in the adult mental health services. On Thursday, 9 December 2004, I launched two reports which resulted from the process, Speaking Your Mind, prepared by Carr Communications, and What We Heard, prepared by the Irish Advocacy Network. The reports reflect the wide ranging knowledge and expertise that exists among professionals and service providers with regard to mental health issues. They also give a clear indication of service users’ views of the present state of the mental health services and how they should be developed in the future. I believe these reports will facilitate further discussion on the role of advocacy services in the development of services for people with mental illness. They will also have a significant impact on the work of the expert group and on the future direction of mental health policy, in which the Mental Health Commission will play a key role. I thank the House for affording me the time to speak on this important issue.
Mr. Browne Mr. Browne
Mr. Browne: I welcome the Minister and his officials to the House. I am amused to see the Minister’s speech include phrases like “are now  being considered”, “should be developed in the future”, “priority” and “commitment”. The word “will” must be in the Minister’s speech hundreds of times and much of the speech is aspirational. The Minister of State and his Department are in grave danger of becoming so bogged down in reports that they will not know where they are going. Perhaps it is time to declare a report-free year, where the Minister of State could begin to implement the reports already available to him. Perhaps it is time to declare a report-free year so that the Department can begin implementing the reports it already has. The Minister of State gave a good speech which was all about plans and priorities for the future. However, there is not much evidence of action. The miserable sum of €15 million for the further development of mental health services in 2005 is surely not even indexed to inflation. I am not confident in the Government’s commitment to this area of the health service. Much work is being done in this area but not necessarily by the Government.
The Minister of State’s comments in the Dáil last week about my colleague, Deputy Neville, do not inspire confidence. It is universally accepted that Deputy Neville, a former Member of this House, has played a significant role in the area of mental health, particularly in regard to his consistent highlighting of the problem of suicide. His contribution should be acknowledged. Perhaps the Minister of State was having a bad day when he made his comment that Deputy Neville’s continuous representations were becoming “a bit tiresome”. The Minister of State may have already given Deputy Neville the clarifications he has sought on this issue.
The recent Government decision regarding the closure of Mountjoy Prison and the associated transfer of the Central Mental Hospital to the new shared site on the north side of Dublin is a matter for concern. Commentators are not in favour of the linkage thereby established between a prison and a psychiatric unit. We often speak in this House about the importance of removing stigmas. The proposed move is not helpful in this regard and indicates that we are going in the wrong direction on this issue.
It has been brought to the attention of the Minister for Finance that the current tax relief schemes for hospitals exclude psychiatric hospitals. The Government should consider the extension of tax relief to the development of psychiatric hospitals. In fairness to the Minister for Finance, he agreed in his reply to a parliamentary question tabled by Deputy Bruton, the Fine Gael finance spokesman, to consider the question of introducing such reliefs for psychiatric hospitals, including geriatric psychiatric facilities. The Minister has received proposals in this regard and they are being examined by his Department. I hope the Minister of State will work to ensure these provisions are included in the next budget.
According to the Irish College of Psychiatrists, mental ill-health affects one in four of us during our lifetime. Four of the ten major causes of dis ability are psychiatric conditions, including unipolar depression, bipolar disorder, schizophrenia and obsessive compulsive disorder. Alcohol misuse is also listed as a factor. Research by Mental Health Ireland indicates that 73% of the population know someone close to them, either a family member or acquaintance, who has or had some form of mental illness. Furthermore, 10% of those surveyed indicated that they had suffered some mental illness, with depression, which affects 50%, the most common affliction. These are grim statistics.
The funding of mental health services by the Government is dubious. It is amazing to observe that funding has decreased from 11% of the total health budget in 1997 to 6.6% now, representing less than half the World Health Organisation’s recommendation that 14% of a country’s health budget should be spent on mental health services. Overall growth in the non-capital health budget between 1990 and 2001 was more than 300%, but the increase for psychiatry was only 131%. During the Celtic tiger years, 1997 to 2002, the increase in overall new capital expenditure was 120%, while the corresponding increase for psychiatric services was only 74%. According to the Irish College of Psychiatrists, when these figures are adjusted for inflation the increases amount to 72% and 36%, respectively.
Apart from the €1 million allocated to the Central Mental Hospital, there has been no increase in the financial allocation to improve mental health services in 2004. There is a lack of rationale behind the allocation of funding in this area to the various health authorities. Urban areas receive half the funding per capita of rural areas, even though urban areas have twice the rate of severe mental illness compared with rural areas. While €100 per head is provided for 100 ill people in urban areas, €200 per head is provided for 50 patients in rural areas.
An area in which Government provision is particularly poor is that of psychiatric services for adolescents, as the Minister for State acknowledged in his speech. There are only 20 inpatient psychiatric beds for children and adolescents nationally, including 12 in Galway and eight in Dublin, whereas 144 are required. As a result, adolescents end up in inappropriate adult facilities. Most child psychiatrists have a waiting list of a year before a child can even be seen. This is contrary to the professional advice which recommends that early intervention is crucial to full recovery.
Furthermore, there is no psychiatric service for adolescents aged 16 and 17 years. Child psychiatry provides services for children up to the age of 16, after which treatment is provided through the adult service. The second report of the working group on child and adolescent psychiatry, which examined the deficit in services for 16 and 17 year olds, was published in June 2003. There has been no action on this report’s recommendations.
 At the beginning of this speech, the Minister of State correctly acknowledged the major role played by the many services promoting mental health. He referred to the 1984 policy document, Planning for the Future, which recommended the establishment of a comprehensive community-orientated mental health service as an alternative to institutional care for persons with mental illness. That is the correct approach and it has worked well.
St. Dympna’s Hospital in Carlow town is an example of what was considered the best approach to the treatment of mental illness in the past. In hindsight, however, we are aware that many patients should have not been sent there. There were some who spent practically their whole lives in psychiatric hospitals. Such events reflect a shameful period in our history which should be examined. Vulnerable people who did not suffer any psychiatric illness were incarcerated in institutions such as this as a consequence of a grievance held against them by a family member, for example. On the other hand, many patients benefitted greatly from their time in facilities such as St. Dympna’s Hospital.
The Minister of State is aware of the current difficulties in regard to Kelvin Grove in Carlow town. The proposal for this facility is contrary to the essence of the 1984 report. There is no question that the level of service provided in the psychiatric hospital at Kelvin Grove is appalling and must be improved urgently. The staff there are working under difficult circumstances. However, the plan by the former South Eastern Health Board to sell the land on which the current facility is situated and build a new hospital across the road involves the removal of soccer pitches on the new site. These sporting facilities were previously used for cricket, and international hockey games have also been played there.
One must query whether this is the correct approach to take. Does it not signify a return to the policy of institutional care? Organisations such as the Delta Centre in Carlow town have done major work in assisting patients with mental illness. Patients are placed in houses so they can socialise within the community while receiving the treatment and support they require. The health board’s proposal, which now comes under the aegis of the Health Service Executive, seems to be contrary to modern thinking in this area.
Will the Minister of State reconsider this proposal? Apart from the prospect of the loss of a valuable soccer pitch in the middle of the town, there are alternatives to consider. My father, a former Deputy, has been involved in this area but the answers he has received from the Minister of State’s Department have been bland, merely referring his query to the HSE, which in turn responds with more letters. The Minister of State should look at that case in particular as it represents a serious issue in Carlow regarding the provision of services to patients.
 According to the Minister of State, the development of child and adolescent psychiatric services has been a priority in recent years. It is time to stop calling it a priority and give it the resources it needs. I hope more speakers will support the Minister of State today. No Fianna Fáil Senator spoke on the Order of Business this morning; perhaps they are getting tired.
Ms Feeney Ms Feeney
Ms Feeney: We let the Opposition have its day.
Mr. Browne Mr. Browne
Mr. Browne: They did not support the Minister of State’s senior colleague in her difficulty with the nursing homes. Perhaps they were saving their energy for this morning’s debate. I look forward to their contributions.
Mr. Glynn Mr. Glynn
Mr. Glynn: Tá fáilte roimh an Aire Stáit go dtí an Teach. Senator Browne asked why the Mental Health Commission was established. I believe it is important this was done. I thank Senator Henry for calling for the debate, on which I was pleased to support her. The Mental Health Commission has pulled all the strands together and produced a very conclusive and informative report. Not alone has it set out the objectives of what psychiatric care should be, but it has also established what has been achieved since the publication in 1984 of Planning for the Future. I remember that document very well. Mr. Liam Flanagan, who was the Secretary of the Department at the time, had a very important role to play in it. This report outlines what has happened in the interim and what we should do in the future. It gives an overview of the service as it is, as it was and as we would all like it to be.
During the last Seanad, I asked that the title of Inspector of Mental Hospitals be abolished and be replaced by an inspector of hospitals. While I did not get my way the present Inspector of Mental Health Services goes some way towards my objective. As mentioned in the commission’s report, most people would agree that the old established hospitals were off-putting. I worked in one for many years and was very pleased to do so. I was very proud of the service that was provided in that institution and others. I was proud to work with male and female colleagues in that institution as well as those in ancillary services.
I wish to refer to the composition of the commission. The finest people available are members of that commission. I refer to two of them, namely, Dr. John Owens, who was a consultant psychiatrist in St. Loman’s Hospital at approximately the time I qualified, and Mr. Joe Casey who is well known as the former chief nursing officer in St. Senan’s Hospital in Enniscorthy.
I spent many years in the psychiatric services. It used to be that the mental hospital was the be all and end all. Senator Browne is correct in pointing out that some inappropriate placings in psychiatric hospitals took place. While these were not as numerous as some might say, I could refer to a number of them. If one took place, it was one too many. Great strides have been made in  the devolution from the hospital-based service to the community-based service. In his address to us this morning the Minister of State gave some very important figures on the numbers of patients now in psychiatric hospitals compared with a number of years ago.
Substantial progress has been made in recent years in ensuring that those in need of mental health services receive care and treatment in the appropriate settings. Health boards have developed and are continuing to develop a modern comprehensive community-based mental health service. This has resulted in a continuing decline in the number of inpatients with a corresponding increase in the provision of a range of care facilities based in the community to complement inpatient services. In December 1984, 12,484 patients were in psychiatric hospitals and units, compared with 3,701 at 31 December 2003. St. Loman’s in Mullingar had more than 1,100 patients and I believe it has fewer than 300 patients now, which represents a huge step forward.
I am a former member of the Midland Health Board and was an officer of the board for many years. The purchase of community residences led to resistance from local people. I was somewhat annoyed that the same people would be quick to identify people they believed should have been in the care of the psychiatric services. They were happy to suggest that such people should go to hospitals and be treated for their condition for a period. However, when those patients wanted to come back into the community the same people showed hypocrisy in not wanting them back and wanted them to stay behind the closed doors and high walls.
I refer to what the Minister of State said about the implementation of the provisions of the Mental Health Act 2001. The rights of some, but not all, who were admitted to psychiatric hospitals, have been infringed and in some cases inappropriate placings were made. I refer to the past in the main; I am not aware of any such cases in recent times. It is imperative that they be entitled to due process. In some cases it was not because they had been diagnosed as having a psychiatric illness but that people were recommended for detention by a Garda superintendent or by a superintendent community welfare officer. It is doubtful that people in such positions had any notion as to what psychiatric illness was about. However, people were detained on the word of such people. I am sure those people were fine people in their own right. However, that was what happened under the Mental Treatment Act 1945 and it was wrong.
The detailed programme of the commission is a matter for the commission to determine in accordance with its statutory functions under the Mental Health Act. However, the commission has indicated that one of its priorities in coming years will be to put in place the structures required for the operation of the mental health tribunals. The mental health tribunals, acting  under the aegis of the Mental Health Commission, will conduct a review of each decision by a consultant psychiatrist to detain a patient on an involuntary basis or to extend the duration of such detention. The review will be independent and automatic, and must be completed within 21 days of the detention or extension order being signed. As part of the review process the mental health tribunal will arrange on behalf of the detained person for an independent assessment by a consultant psychiatrist and the commission will also operate a scheme to provide legal aid to patients whose detention is being reviewed by a tribunal. This process is expected to commence in 2005. From a human rights point of view this is imperative. While it should have been done years ago, as the old saying goes, it is never too late to do the right thing.
The commission report also refers to nurse training. While the psychiatric services have some 5,000 nursing professionals, the age profile is unsatisfactory. Back in the 1980s many if not all the training schools were closed. One was closed in St. Fintan’s in Portlaoise, in my health board area, and another was closed in St. Loman’s in Mullingar. Based on its results, St. Loman’s had the unique distinction of producing the finest students in the country.
When the nursing schools were closed, they were not replaced. I fought a battle for 14 years before a college of nursing was established in the former Midland Health Board area. The former Minister for Health and Children, Deputy Cowen, established such a college, with links to Athlone Institute of Technology. The training of psychiatric nurses has recommenced, thankfully, although it has happened somewhat late in the day. The report states that the age profile of the psychiatric nursing profession is unsatisfactory. I understand that the average age of a psychiatric nurse is 45, which is not acceptable in such a profession.
Reference has been made to funding. Everyone accepts that the community-based service is by far the best one. As someone who has always been passionate about this area, I certainly accept that view. The Mental Health Commission report points out that such a service ensures that people are treated with the minimum of disruption to their lives. I do not doubt that the placement of former patients of psychiatric hospitals in high-support, medium-support or low-support community residences is by far the best way to treat psychiatric illness. Indeed, such people are sometimes discharged into the community. People who are committed to psychiatric hospitals on an involuntary basis need special care. I ask the Minister of State to consider the provision of three or four special care units for such people. As the behaviour of such people is so challenging, the units should have a small number of residents and a high level of staffing, possibly on a one-to-one basis. The people in question are a potential  danger to themselves and other members of society.
I will not speak for much longer because the Minister of State summed up this matter well in his speech, but I wish to refer to the need for new acute psychiatric units at general hospitals. I have argued that there is a need for longer-stay units. Successive Ministers have agreed with professionals in this area who have said that the best approach is to locate an acute unit in a multidisciplinary setting on the campus of a general hospital. They are right to advocate such an approach. The Minister of State referred to the number of new units which have opened.
I assure Senator Henry that phase 2B of the project in the Midland General Hospital at Mullingar is ongoing. I am pleased that a new psychiatric unit will be developed there. Provision will be made for additional child and adolescent psychiatry services which are being provided at Mullingar at present, although not to the extent we would like. I note the Mental Health Commission’s important comments about services for people in their late teens. My experience has taught me that people in that age group can encounter serious difficulties. The necessary facilities to cater for such people have not been in place. There is a psychiatry of later life unit at St. Loman’s Hospital in Mullingar. I will not mention the name of the excellent consultant who works there, as he is not a Member of the House. I do not doubt that the unit has had great success as a consequence of the work of that consultant.
I wish to conclude by talking about suicide. One of my first experiences when I was a trainee psychiatric nurse was to be given what was known at the time as a “red card”. That meant I had to ensure that a patient in my care did not commit suicide. It was outrageous to give a young nurse such a responsibility. The patient in question was approximately 6 ft. 3 in. whereas I was approximately 5 ft. 7.5 in. and approximately ten stone. One can imagine what would have happened if he had wanted to do something. I would have had little chance of preventing him from doing so. My colleagues and I succeeded in ensuring that he did not commit suicide, thank God, and nothing happened.
The study of suicide has not progressed as a science. As I have said on previous occasions in the House, few families or homes have not been touched by the cold fingers of suicide. Young males are primarily the victims of suicide. We can all help to combat this social problem. There is a significant demand among young people for moral support. It is true that the young people of today are better educated than previous generations, but that does not mean they do not need to be supported. Every member of society has a role to play in preventing suicide. A certain individual with whom I was very familiar committed suicide in the not too distant past. It happened out of the blue — there were no signs, symptoms, utterances or other signals such as body language. I am as wise today about what caused it as I was  at that time. I do not know what caused it and neither does anybody else.
The report of the Mental Health Commission is timely and extremely important. The Minister of State and I have discussed the psychiatric sector, in which he has an abiding interest, on a number of occasions. It needs to be given greater funding. When a problem is diagnosed and a prescription is written, the prescription needs to be funded. I ask that the many great proposals in the commission’s report be implemented. Everybody should co-operate in their implementation.
Dr. Henry Dr. Henry
Dr. Henry: I welcome the Minister of State to the House and his speech on this issue. I am grateful to the Leader of the House for acceding to my request to debate the 2003 annual report of the Mental Health Commission. I wish such a debate was held automatically. When I was first elected to the Seanad 12 years ago, the report of the Inspector of Mental Hospitals was never debated in the Oireachtas. I am sure the Minister of State is aware that the reports were not even printed at one stage in the past. It was a useless exercise to employ people to put a great deal of work into such reports because nobody took any notice of them. The work of the commission is an important part of our health service. I would like the Seanad to be obliged to discuss its report every year.
I appreciate that the Mental Health Commission has not been established for very long. The House has considered the first report of the Inspector of Mental Health Services. It is important to note the change in name to refer to mental health “services” rather than mental “hospitals”. The final report of the Inspector of Mental Hospitals has yet to be published. The change in name reflects the change from providing institutional care to providing as much care as possible in the community. It is important to inspect services, rather then just institutions. I am delighted to have an opportunity to address this matter today.
As the Minister of State pointed out, the expert body on mental health policy is formulating a new national mental health policy. I wonder how it is going. I am sometimes concerned that when certain bodies are established, not much action is taken for a very long time. I would like to know how much progress the expert body is making.
I am pleased by the some of the actions taken by the Mental Health Commission to date. I am glad it supported the smoking ban because it felt patients and workers in mental health institutions are as entitled to a smoke-free environment as everyone else. Other developments are progressing at a snail’s pace, however. For example, what has happened to the proposal to establish mental health tribunals, which was one of the most important aspects of the Mental Health Act 2001? The Minister of State is aware that under the Act, the cases of people involuntarily admitted to hospitals — there are hundreds, rather than thousands, of such people — have to be  reviewed within 21 days by a mental health tribunal comprising a psychiatrist who is not the psychiatrist who was involved in admitting the person, a lawyer and a lay person.
Interviews have taken place with lawyers and lay people but it is apparent that the dispute between the Minister for Health and Children and the various consultants over the historical liabilities associated with the Medical Defence Union has put a stop to any interviewing of psychiatrists for the positions in question. This dispute has been ongoing for well over a year. I dread to think about how much longer there may be a delay in establishing the tribunals. They are terribly important. One of the major reasons for introducing the Mental Health Act 2001 was to update the Act of 1945. We have been found to have been in breach of the European Convention on Human Rights. Will the Minister of State outline the position on the tribunals in his reply?
Today is the second anniversary of the introduction in this House of the Criminal Law (Insanity) Bill but we still have not proceeded to Report Stage, bearing in mind that the European Convention on Human Rights ordains that such legislation should be enacted urgently. I do not agree with a great deal of the legislation. I tabled many amendments on Committee Stage and have also tabled amendments for Report Stage. The Minister for Justice, Equality and Law Reform only listened to our complaints about the Bill and did not give any replies on Committee Stage. We will have to have a Report Stage that is more like a Committee Stage, but we will not have the chance to reply to the statements of the Minister more than once. This is a great disappointment to me.
An Audit of the Pathway to Involuntary Admission published in 2002 did not discuss the position on legal aid for people admitted involuntarily under the Act. Is anything happening in this area? Consider the views of the committee on intellectual disability and mental health services. I do not believe the Minister mentioned in his speech anything about people with an intellectual disability in addition to a mental illness. This is not uncommon. We still have people with an intellectual disability in psychiatric institutions although people in both categories are being segregated more than they used to be. I am sure the Minister of State wishes the placing of those with intellectual disabilities in psychiatric institutions were not happening as much as I do. There are significant differences in the way both categories should be dealt with. This matter must be addressed urgently. It is described as being a priority for the commission. How significant a priority is it in reality?
I was delighted that there was a conference on child and adolescent psychiatry. We realise more and more frequently that early intervention is essential in the treatment of mental illness if the best possible outcome is to be achieved, as is the case with all illnesses. The Inspector of Mental Health Services, Dr. Carey, pointed out the woe ful lack of inpatient beds for children. Some of the children in question can be very seriously ill and in need of inpatient treatment.
I am quite sure the Minister of State will be aware of an interesting survey carried out in Clonmel recently by the social services, the purpose of which was to determine the extent of mental illness in children in the area. I compliment those involved in the study. They examined children aged between one and a half years and 18 years and found that up to 20% of children had a significant mental illness problem. They did not choose Clonmel because they believed there was a problem peculiar to the town, they picked it because it had a good urban-rural mix. I have not seen the details of the report. I have only seen the press reports but they seem to indicate that there is a serious problem that needs to be addressed.
Bullying has been discussed. It is a very significant cause of suicide among children and teenagers. A very good pilot scheme to introduce anti-bullying measures in schools was carried out in the area under the jurisdiction of the former North Western Health Board, mainly in Donegal. Despite the fact that it was found to be extraordinarily effective there has been no effort to extend the scheme to the rest of the country.
Bearing in mind the various disciplines associated with mental health, we must question the effect of the decision to refuse 80 children places in secondary schools in Limerick, the city from which the Minister of State comes. What will this do to their self-esteem? Their parents must be in a state of terror. The transition from primary to secondary school is reckoned to be extraordinarily important. I have often heard educationalists argue that it would be better to have remedial teachers for pupils in the first year of secondary school than in the more senior classes in primary schools because if they despair when they enter the first year of secondary school, the situation is dire. The Government is not taking the matter of child and adolescent mental health seriously enough. We are allowing issues that are perfectly obvious to us all to continue to arise.
The Inspector of Mental Health Services rightly pointed out the major contribution to improving standards in mental health services made by the former Inspector of Mental Hospitals, Dr. Dermot Walsh, and his assistants, Dr. Liam Hanniffy and Mr. Michael Hughes. Reports from as recent as ten years ago contain complaints about the sharing of clothes and underwear and unsatisfactory food, for example. In more recent years, one finds these problems no longer arise. Therefore, the work of Dr. Walsh and his assistants certainly needs to be recognised. I look forward to seeing their final report.
It is important to examine the activities of the psychiatric services in conjunction with this report. The 2003 report has been published recently. I am sure the Minister of State, like me, was interested to see the variations in treatment  around the country. What was most noticed by the press was the difference in the frequency of the use of electroconvulsive therapy. It is virtually never used in some areas, yet is used quite frequently in others. It was interesting to note in the report that areas with the most complaints frequently had the most requests for information under the Freedom of Information Act. It is important that staff working in mental health institutions understand that patients and their relations, or whoever is acting on their behalf if they are not in a position to make inquiries themselves, are entitled to information on their treatment and the admission policies of various hospitals.
We have frequently spoken about the public perception of mental illness and mental health. Promotion is required in this area. Many voluntary groups are trying to lessen the stigmatisation of those with mental illnesses. I applaud the work done by many of these groups, including Schizophrenia Ireland, Aware and Amnesty International. I commend the efforts made at school level to point out the importance of mental health. The commission has a very serious role in promoting mental health, not just in dealing with ill health. I hope it will address this.
I recall the launch of Planning for the Future. It is good that there are more community-based residential schemes throughout the country and more day hospitals. More people are being treated at home and more are being treated by interdisciplinary teams than was hitherto the case. This must be difficult for those who have been working in psychiatry for some time to accept because psychiatrists in particular are used to working as individuals with individual patients. However, it has been recognised that interdisciplinary teams, which include therapists, psychiatric nurses and community psychiatric nurses, produce the best results. While it is challenging for everyone, I hope it is appreciated that the skills mental health service staff will need to acquire will be important to the development of psychiatry in this country, as will their contributions.
The Inspector of Mental Health Services mentioned various areas, including the psychiatry of old age. This will become more important as people live longer and there is a shortage of psychiatrists in this area.
Rehabilitation of people with severe and enduring psychiatric illness and psychosis is difficult because, if possible, one wants to treat them at home. Binge drinking and abuse of drugs, which may be important factors in suicide, are omitted, as are eating disorders.
It is regrettable that this report did not address forensic psychiatry which is seriously underdeveloped. There is only one facility, the Central Mental Hospital, which is the subject of serious concern. The facilities in the hospital are dreadful. There is a preservation order on the main building which has no sanitation. It is exactly as it was when Queen Victoria came to the throne. While  such accommodation is unacceptable, is it right to move a hospital to a prison complex? This may happen and if it does, the hospital may be governed by the Prison Service.
At least one third of the people in that hospital have not been involved in crime but have been put there for their own safety or that of others. This needs to be carefully considered. There are no low-security facilities in the country to which some people could be diverted from the courts or prison, or to which people from the Central Mental Hospital can be discharged. Meanwhile, we must take care not to incarcerate people who do not need to be incarcerated simply because we have no low-security units. This is important.
The pressure on beds in the Central Mental Hospital has resulted in many people with a psychiatric illness who are in prison being treated there and not in a hospital. It is a help that psychiatrists go into the prison but it is not enough.
While I welcome any increase in money spent on mental health services, recent figures from the Department of Social and Family Affairs show that the amount of money spent on long-term disability payments for those with mental illness was higher than the total spent on the mental health services, including the upkeep of buildings.
Ms Feeney Ms Feeney
Ms Feeney: I welcome the Minister of State at the Department of Health and Children, Deputy Tim O’Malley, and thank him for his regular attendance here which we appreciate. I am delighted to have an opportunity to speak about the second annual report of the Mental Health Commission. I commend the hard work of its chairman, Dr. John Owens, and Ms Bríd Clarke, its chief executive officer.
It is widely acknowledged that there have been significant advances and much needed change in the delivery of mental health services over the past ten years. I am concerned about child and adolescent psychiatry and was interested to read, on page 35 of the report, that estimates suggest that services for this group require in the region of 120 beds nationally; for those with intellectual disability, some 220 beds are required while 30 beds are needed for those with eating disorders. Those estimates may even be low. There is an urgent need to put in place a planning exercise to ensure those beds are available.
Senator Henry referred to the study reported in The Irish Times on Tuesday. I was interested to read that Clonmel was selected because it had a good mix of urban and rural population. The study covered 4,000 children under the age of 18 and as young as 18 months. I was somewhat shocked to read that 17% of adolescents suffer from a significant form of mental illness.
In preparing for this debate I spoke to a child psychiatrist who said those figures were already known. I was surprised to learn that 12% of pre-school children are suffering, as are 11% of those in national school and 24% in secondary school. That will be the major problem in future for all the reasons outlined this morning. Adolescents  are the most vulnerable group, whether due to their social life, with excessive drinking, exposure to drugs or bullying in school. However, whatever the cause, 24% is much too high a figure.
Of the 17% established as having serious mental health problems, 8% will do well because they have access to good primary care services. These services can cater for them only where there is a good general practice service, counsellors in schools and where community care services and social workers are adequate and working. Sadly, the remaining 9%, who should receive treatment, do not; only 1.5% of that 9% see child psychiatrists.
I am pleased that in the recent Cabinet changes the Minister of State retained the brief he has held since 2002 because continuity will ensure the delivery of the best services. The planning committee he set up is considering developing units and inpatient beds for child and adolescent psychiatry. Money has been earmarked for this area. When will those units in Cork, Dublin, the mid-west, and possibly one other, be ready?
I know the pain a parent, or parents, undergo when they have a child or adolescent suffering from mental illness. Before Christmas I raised this issue on the Order of Business because a tragic story about a 14 year old boy had come to my attention. He needed hospital care but no hospital was willing to take him. He was eventually admitted to one of the main psychiatric hospitals in Dublin. However, while he was being admitted he disappeared and, sadly, a few hours later he was found dead. Nobody will ever know what his parents must be going through.
There is another case where a 13 year old needs to be hospitalised but because of the case before Christmas psychiatric hospitals are afraid to admit adolescent patients for whom they do not have any beds.
I am aware the Minister is working hard in this area and that he is a caring person. Money needs to be invested in child adolescent psychiatry services. We need to bring beds on stream for the treatment of such children.
Representatives from Aware appeared before the Oireachtas Joint Committee on Health and Children three or four weeks ago. We discussed community care settings and the wonderful work being done. Those settings have proved to be far more beneficial than the big old hospital setting. The representatives brought to our attention that patients were being brought out of the big institutions into a smaller institution, in that they are being housed. The Minister of State should ensure that such patients are allowed to enjoy independent living because the representatives said they are not being allowed the independence the community setting was established to give them.
I wish to comment on acute units. When I was a member of the Medical Council I had the opportunity three years ago to visit an acute unit, the Jonathan Swift clinic, that is attached to Tallaght Hospital but which was previously based  in St. James’s Hospital. That unit is a blueprint for the way forward. It is a beautiful unit. It took a while to get used to the level of security needed in an acute unit. Doors automatically lock when one goes through them and that is a necessary safety provision for a person suffering from a mental illness. The unit is a modern building with bright painted walls. There is no sign of the drudgery to which we would have been accustomed in the old mental institutions. There were flowers in the unit, beautiful paintings on the walls and the soft furnishings were comfortable. It was almost like a home from home. Is that not the way forward? The more acute units of that style we have, the better.
I am disappointed my colleague, Senator Browne, has left the Chamber. He should not read anything into what happened on this morning’s Order of Business. I was not in the Chamber for it as I was preparing for this debate. Regardless of which Members on this side of the House are members of Fianna Fáil or the Progressive Democrats, we would have no difficulty in defending the Tánaiste or any other Minister. We do not believe the Tánaiste needed defending this morning and perhaps that is the reason there was silence on this side of the House. We were allowing Opposition members to have their say.
Mr. Feighan Mr. Feighan
Mr. Feighan: I welcome the Minister of State. It is welcome that the Mental Health Commission was established in April 2002 under the provisions of the Mental Health Act 2001 and that a modern framework is being provided for people who need treatment or protection. The Mental Health Commission is the main vehicle for the implementation of provisions of the Mental Health Act 2001.
Those who suffer from a mental illness have for too long constituted a hidden society. We must be aware not to make the mistake that was made in the UK of returning persons to the community who are ill-equipped to cope with life. I am pleased about the amount of resources that have been allocated to the area of mental health in recent years. I am sure previous speakers have referred to the State-run institutions in which the conditions were Dickensian. A more holistic and caring approach has now been taken to the provision of accommodation for people suffering from a mental illness. Before I became involved in politics and was an outsider, so to speak, I did not realise the progress that was made over the years in bringing people out of such institutions into the community. While one or two problems have arisen, the benefits of that approach have far outweighed those one or two problems. Some people also adopted the “not in my back yard” approach to the provision of such accommodation. They were of the view that it was inappropriate that people who suffer from a mental illness should be placed in the broader community. I am glad their fears have been allayed and issues of serious concern have not arisen.
 The role played by various organisations such as Mental Health Ireland, GROW, Aware and Schizophrenia Ireland is important. They need a professional focus and guidance which must be delivered. Is there liaison or an open line of communication, which I hope there is, among those organisations which provide a valuable service? If the Department can assist in that respect, which I am sure it does, by bringing the various strands together at certain times, this would ensure the best service is provided and that people would not fall through the safety net.
Some 10% of the population have suffered from a mental illness, with depression being the largest single factor affecting 50% of those people. I am sure the weather does not help in that respect. We must provide more sports facilities, holistic medicines and alternative practices to help prevent mental health problems arising. I am not being critical of the Government but adequate funding is not being allocated to the provision of leisure centres, swimming pools, etc., although many such facilities have been provided, including a state-of-the-art leisure centre in my county of Roscommon which is being well used.
The Department of the Environment, Heritage and Local Government has been responsible for the building of many roads and bypasses and up to recent years it was not a requirement to provide for a footpath when constructing such roads. Ireland is unique in comparison with most European countries in that men, women and children go out walking on our roads and streets. The exercise of walking goes a long way towards preventing depression which may lead to the development of a mental illness. A bypass was built in my area and it is pleasant to go for a walk on a footpath that is well lit and where one feels safe from passing traffic. There should be more liaison in this area in terms of the provision of leisure centres, alternative medicines and safe places for people to walk. People go out walking every night and the Minister of State should liaise with the Department of the Environment, Heritage and Local Government to ensure that bypasses include footpaths. A footpath was provided on the N4 bypass and at any time of the day or night at least ten or 15 people are using it. The numbers who avail of a footpath make it a valuable resource and good value for money.
While €1 million has been allocated to the Central Mental Hospital, there has been no increase in the financial allocation to improve the mental health services. There is a need for quality community-based care and while it costs as much as inpatient care and results in similar outcomes, the patients are better off socially and vocationally.
I pay tribute to the VECs around the country — they have done much work in providing classes and assistance — but I have a difficulty with the Prison Service. Not enough finance is being given to the Prison Service for educational facilities and in some areas the health service within the prisons has been compromised. Many people in  prison suffer from schizophrenia or depression and more should be done for them.
We must implement the recommendations in the report of the national task force on suicide. Mental health has long been regarded as a hidden illness but we have become more open about it over the years. We have come a long way since there were institutions with 20 ft. high walls and much more can be done. Implementing the contents of the report would be a good start.
Those who suffer from mental illness have civil and human rights and we must encourage measures to combat the stigma attached to mental illness. We must establish consultant-led multi-disciplinary teams where the Minister of State can liaise with the Departments of Education and Science and the Environment, Heritage and Local Government to ensure there are more resources in every town. If every town had a fully-equipped leisure centre and a dietician service, it would help prevent mental illness.
Depression is a major element of mental health problems and we must do all we can to assist in its treatment. Studies in recent years have shown that the herbal remedy St. John’s Wort is almost as good as Prozac in treating depression. It is sad that a natural remedy for depression that is as good as many drugs is now only available on prescription. People can go to Northern Ireland and buy as much as they want quite cheaply but a prescription is needed here. This remedy should be made available again.
Mr. Lydon Mr. Lydon
Mr. Lydon: Regarding Senator Feighan’s comments about the Tánaiste, her statements have an adamantine veracity about them and her integrity is unassailable.
I welcome the Minister of State to the House. He is a caring man and will take some of the remarks made this morning in the spirit intended because they are aimed at helping a vulnerable sector of our population.
In 1984, the Planning for the Future document charted a course for a community care model of psychiatry which, for the most part, is very good. There are, however, deficiencies. The larger institutions were closed down. They were Victorian and out of date but many of the people who were discharged were incapable of functioning in a community care model. It was incorrectly assumed that some people with long-term illnesses, particularly schizophrenia, would be able to operate from group homes and do all the things people do without much support, or even with it. That is not what happened. Many of the people who had places in some of these hospitals ended up homeless.
It was right to close down the large hospitals but in the smaller psychiatric hospitals, people had a routine, support and their own lifestyle, with the hospital acting as a town or village in the community. Most of all, they felt safe and secure. They did not want to cope with some of the problems presented by life; they needed to be cared for. Although the community care model pro poses that this be done within a group home setting, it is not the same and it is sometimes difficult for people. We must recognise that there are people who will always need care in a hospital not because they will do anything out of the blue, but simply because they are unable to cope with the vicissitudes of normal life. They are vulnerable and they need help. It behoves every Government, irrespective of party, to look after these people.
I feel for these people because I have seen some of them who were forced out of hospitals, who wandered around and came back in temporarily for respite care or as the result of an acute breakdown. It was expensive to house them permanently in hospital. Many would say it was demeaning but it was not. They had a routine in their lives, they knew where they were, and they were secure and safe.
The rest of the community care model is excellent because it involves everybody — general practitioners, psychiatrists, social workers, psychologists, community nurses and so on. Where it works, it works well but it is a very expensive model. It requires a huge support team, which is not always provided. For most illness types it works well. It works for people who can reside in group homes or in their own homes and for people who only need respite care from time to time.
Another issue to which I want to refer is adolescent psychiatry. I do not say child and adolescent psychiatry but adolescent psychiatry. Adolescents are a special group, especially those between the ages of 12 and 18, sometimes younger, sometimes older, depending on the maturity of the person. This is a special group of people who are not children and who are not yet adult. Sometimes they are adult in a physical and intellectual sense but certainly not in an emotional sense.
I am familiar with this cohort. I was the first psychologist ever to be awarded a Council of Europe medical fellowship to go abroad and study the residential treatment of disturbed adolescents. I later served on the then Department of Health consultative body on the residential treatment of disturbed adolescents. No matter how we tried nothing really happened. Dr. Tom Brennan, a wonderful psychiatrist and one of the most erudite and caring men I have ever met — I say erudite in the widest sense of the word — was a member of that group. We subsequently opened an adolescent unit at St. John of God Hospital but were eventually forced to close it.
There are two places in the country for adolescents, Warrenstown House and St. Anne’s in Galway, but there is a need for many more. The reason these are not provided is that they prove so expensive to run. Such units must work not only with the adolescent but with his or her family. A family-based approach is essential because one cannot possibly alter a young person’s behaviour in any way without dealing with the parental expectations and so on. Much work  is required involving many people, including psychologists and psychiatrists. I am glad more child and adolescent psychiatrists have been appointed. However, they are mostly child and adolescent psychiatrists and are not specialists in the area. Dr. Tom Brennan was one of the first adolescent psychiatrists to be appointed here and Dr. Terence Larkin is also a wonderful adolescent psychiatrist.
A psychiatrist cannot run a unit like this on his or her own. It requires specialised nursing, not just psychiatric nurses but nurses who have some interest and training in adolescent psychiatry. Adolescent psychiatry is different from child psychiatry and is much different from adult psychiatry. Adolescents are a very vulnerable group. I am not criticising any Government in my comments. Even the Minister of State said here today that the working group noted that many of the child and adolescent psychiatric teams currently in place do not have the full complement of team members required and recommended and that priority should be given, in the first instance, to the recruitment of the required expertise for the completion of existing teams. I praise the Minister of State for that statement because it is an acknowledgement that a service does not exist and this must be a priority. I would like the Minister of State to put some effort into this area — I am not saying he will not — because adolescents are a group that can be helped.
I have seen adolescents change their behaviour again and again. I worked in adolescent psychiatry for approximately five years and had connections with it afterwards. There is a wonderful organisation called Citywise. It is run by a man called Mark Hamilton. He started a little place in Dublin and now has a large place in Jobstown. He enlisted the help of local builders and developers and is building a large facility. He has a place in Belfast, one in Limerick and another somewhere in the midlands. The adolescents he takes in have no hope. They are usually illiterate, wild, totally unruly and come from broken homes. Some of the parents are drug addicts, murderers and so on, yet he fills them with a sense of their own well-being, somehow motivates them and shows them there is hope in life. I commend people like that. He does not deal with psychiatric problems. Some of the people he deals with have psychiatric problems, but that is not his primary function.
Even the unit in St. John of God Hospital, which is quite a good hospital, had to close because it did not have the required staff. The staffing complement for such units is very high as adolescent services are very expensive to run. The State must ask itself whether it is worth investing in a young person. I can tell the House from experience that it is. Many of them can come out at the other end, have a meaningful adult life, get a job, get married or settle down. If there is sufficient input into their treatment, they can blossom. Some people will always have severe psychi atric illnesses in their adult life, but with medication or through other means will sometimes live a normal life. Although they may sometimes have a relapse, for the most part they can be helped.
I implore the Minister of State to focus on this area. If somebody leaves a child on one’s doorstep one would need to be very heartless not to do anything about it. Somebody will care for the child. An adolescent in a family who has behavioural problems or psychiatric problems or an illness of some kind affects the whole family, not just himself or herself. There is a ripple effect; older and younger children are affected as are the parents who must devote so much time to this person. I am not referring to autistic children or people with neurological problems. I could range over many different areas of psychiatry, but this is one area I know about and about which I am concerned. I am glad the Minister of State made that acknowledgement in his speech. On behalf of these adolescents, so many of whom I have met, I ask the Minister of State to do his best to get the facilities for them. It would ultimately pay the State to help them, and this would ultimately benefit society as well as the children and their families.
Mr. U. Burke Mr. U. Burke
Mr. U. Burke: I welcome the Minister of State, Deputy Tim O’Malley, to the House and am grateful for the opportunity to discuss this important report. I acknowledge the persistent demands of Senator Henry to the Leader over a long period to have this report brought here for discussion and I thank her for her endeavours.
I also acknowledge the stated commitment of the Minister of State to improving the state of mental health facilities and to introducing what he calls community-based facilities. Nobody in the House would disagree that improvements have been made over the years. In 1984 there were 12,900 bed occupancies in mental health institutions and in 2003 or 2004 that had decreased to approximately 2,800. That is welcome because patients who were lucky enough to get out of the institutions left behind a very dark and sad episode of their lives, perhaps a decade of institutional misery, given that the conditions in many of the institutions were of a deplorably low standard. That they have moved into community-based centres is welcome. Essentially what it means in my health board area is that we have placed patients in rented housing accommodation. They are domestic houses and by and large they are rented or leased by the health board. Over a period more patients were taken out of the institution. That is fine but it has a serious shortcoming in so far as there is a lack of therapeutic services available to them in those situations. They are in a house and are comfortable and some type of domestic life has been re-established but they do not have the services they require for rehabilitation.
While the Minister of State has given a commitment I am not speaking about the availability of  funding alone but the whole area of rehabilitation. Senator Lydon mentioned that where it works, it works well. As a person directly involved he would understand the shortcomings.
In addition to the scattering of small groups of patients into communities, it is appropriate to acknowledge the wider community for its acceptance of these community centres. In a sense it is therapeutic for the community at large to realise these are people who have suffered for many years in institutions and now they are out in the ordinary community. They are welcomed into most communities but much more is needed and I do not know how it can be structured. Given that 70% of admissions are re-admissions, it is only then the penny drops that there is an inadequacy in the whole area of therapeutic support and rehabilitation. It is clear from the report of the inspectorate that is an area that is in serious need of assistance and it should be addressed urgently.
There are within some of our psychiatric institutions, particularly in the Western Health Board area, patients who are inappropriately placed. I refer to people with special needs and some disability and they have been in those institutions for decades. While great efforts have been made to relocate them in new centres it is a damning indictment of neglect by the Department and Ministers over the years that no other accommodation was available for those with special needs and a disability of some kind, other than mental disability. They were in those institutions because of absolute need and the inability of parents or family to retain them in their homes. I hope that within two or three years nobody will be able to identify a person misplaced in the psychiatric service when the problem is not psychiatric and that they will be placed in appropriate institutions.
We have been informed there is a clear commitment to those with disability and special needs under the Education for Persons with Special Educational Needs Act and the Disability Billwhich is before the other House and that they can be provided with the funding and facilities needed to give them their proper recognition in society.
Another issue highlighted in the report is that mental illness is treated largely in isolation and co-operation with primary care appears to be non-existent. This is clear from the fact that the number of referrals through general practitioners is small relative to other countries. That speaks volumes. I refer to a tragic incident which took place near where I live. It involved a patient who had been re-admitted on several occasions for treatment in a psychiatric hospital in the west of Ireland. He presented himself on a Friday morning to a general practitioner for help and assistance. He was crying out for help and assistance. The general practitioner contacted a particular hospital and was told the relevant consultant would not be on duty until the following Tuesday and he would see him by appointment on that  day. Tragically that person was buried by then, having committed suicide. That is a classic example of where our services have stonewalled the needy. This person was crying out for help but that cry was rejected, resulting in a tragedy for a family. There are many similar cases. That incident occurred in 2004 and I would hope it would never recur in any part of Ireland. This case is a carbon copy of the inadequacies of the follow-up in existing services.
Senator Lydon said there was a necessity for a team approach and that many in the caring professions must be involved. They are not involved and are removing themselves from it for reasons best known to themselves. That has to change if we are to have a full and comprehensive response to the needs of those with mental illness.
St. Brigid’s Hospital in Ballinasloe is slowly but surely losing its patients through the community service. The numbers have fallen from 1,200 a few years ago to a small number today. I do not fault the existing community service but it is inadequate in respect of its therapeutic and rehabilitation services. Even though patients are placed in the community, which is an improvement on the conditions from which they have come, they are isolated as they are cut off from the services they need.
Can the Minister of State give me an assurance that the resources that will accrue to the Health Service Executive from the sale of property and lands at St. Brigid’s Hospital, Ballinasloe, will be ring-fenced for the development of mental health services on the site made available by the Western Health Board at Portiuncula Hospital, and the other services, if needed, in the east Galway mental health service area? It is important to have clarity on that issue. Many people who are in a state of uncertainty say the Department will take it back and use it for the overall national health service. That cannot happen if we are talking about the delivery of a first-class service which we traditionally had at St. Brigid’s Hospital, Ballinasloe. We want a new modern comprehensive mental health unit with all the necessary rehabilitation and therapeutic units required for St. Brigid’s Hospital in Ballinasloe. Are statistics available to the Minister of State to show the reason for such a high level of re-admissions to mental hospitals? This is not peculiar to any one area and there must be some reason for it. Is it an inadequacy in the treatment process? Are patients being discharged too early? Have they been properly assessed? A problem exists which must be resolved. Tragically some patients are never re-admitted because of situations that occur.
I find it difficult to comprehend the situation regarding the 2003 annual report. The other report is to be published separately at a later date. Is the current inspectorate not confident about what happened in the past and could not relate to it or is this a case of a new broom sweeping clean and the inspectorate wishes to maintain its independence?
Mr. Scanlon Mr. Scanlon
 Mr. Scanlon: I wish to put on record an acknowledgement of the great work done by the mental health associations across the country. My home town has a mental health association and a young mental health association. Those groups did significant work to help remove the stigma attached to mental health, such as visiting patients in the hospitals. Young people aged from 16 years upwards were involved in the association which did a fine job in bringing the issue of mental health out into the open. It taught people to respect this complex illness and those affected by it.
It is a very difficult illness to treat. In the past, a terrible taboo was attached to mental illness. Services for those with mental illness have improved over the years even though there is more to be done. The use of group homes is an excellent idea. There are three group homes and a day centre in my home town. People who in the past would have lived in a mental institution for the rest of their lives are enabled to live in group homes. They can lead a normal life, go about their business, go to mass, travel and meet people. An excellent service is provided for them. The day centre arrangement allows patients in rural areas to be collected daily. They are given their lunch and are seen by a doctor on a daily basis. Those not attending a day centre but living at home are attended daily by mental health nurses. I know some nurses and they are dedicated to their patients. They will call to see their patients if need be at 9 a.m. or at 11 p.m. to talk to them and help them remain living in their own homes.
Thankfully, none of my family has been affected by mental illness but it can happen to anybody. A number of years ago, a good friend of mine dropped dead at 44 years of age. He had six young children, the eldest of whom was 15 years of age at the time. This young man eventually went to college and was doing very well. Unfortunately, he was the person who found his father dead; his father walked out of the house and collapsed and the young man walked out after him. Three years later and for no apparent reason, the young man was struck down with this illness. He was taken to Sligo General Hospital where he was well treated. The staff were concerned about him. I remember the anguish of his mother when she was informed that he needed to be admitted to the local psychiatric hospital, St. Columba’s. She suffered great anguish in making that decision. She believed he would be stigmatised for the rest of his life because he had been admitted to a psychiatric hospital. I visited him on a number of occasions in the hospital. There was no question that he needed the treatment and the staff were excellent.
Traditionally, mental institutions were old, dreary places which suffered from under-investment over the years. Mental health is the poor relation of the health services. It has been proposed that a new psychiatric unit be built on the campus of Sligo General Hospital and this is being con sidered by the Department of Health and Children. I ask the Minister of State to examine this proposal and ensure it is advanced as much as possible. Where possible, those services and new facilities should be provided on the campus of general hospitals, with access to the medical services of the general hospital. This would help abolish the stigma attached to mental illness and patients would not regard themselves as being different from everybody else. Funding should be made available because the lack of finance which was the case over the past 50 years has not helped that service. I acknowledge the service is improving and I have no doubt the Minister of State will continue to ensure that there is an improvement.
Mr. T. O’Malley Mr. T. O’Malley
Mr. T. O’Malley: I thank Seanad Éireann and Senators Henry and Glynn who were responsible for this debate being held. I thank all Senators who contributed to a very mature discussion on the area of mental health and the work of the Mental Health Commission. I will endeavour to respond to as many points as possible in the time allowed.
Senator Browne made a good suggestion about a report-free year. Many reports are in train and they must be allowed proceed, but I agree with the Senator that more action is required rather than reports. Obviously, the action must be evidence-based and planning is required. Often there is a duplication of work and I would much prefer to see it centred. I have spoken to the suicide research group and I will be speaking to more people to ensure that research is carried out from a central base rather than being dissipated among groups around the country expending their energy and resources in the replication of work.
The Senator referred to Deputy Neville. The Senator may be correct that he got me on a bad day. We all have off days. I acknowledge the work Deputy Neville has done in the area of mental health and have no fear of contradiction in stating he has been a key spokesperson in this area. However, without seeking to start a discussion on the issue, I will repeat an earlier point about which I feel strongly, that the way forward is to discuss solutions rather than constantly repeating problems. This is not meant as a criticism of Deputy Neville or anyone else. The discussion today has been mature and most Senators have looked forward rather than backwards or blaming the Government. Mental health services are too important and the issue too sensitive to be politicised.
I understand the genuine concerns people have about the proposal to locate the new Central Mental Hospital in north county Dublin on a site adjacent to a new prison. A project team based in Dundrum did significant work on this issue and considered all the options. These were as follows: development of a new facility on a greenfield site in the greater Dublin area; development of a new facility on a greenfield site outside the greater  Dublin area; refurbishment and upgrade of the existing facility to accommodate the service; partial new building of the hospital with retention and refurbishment of some of the existing building; transfer of the service to another existing facility; or no action. Every option was considered.
I visited the 150 acre site recently. While the proposal regarding the Central Mental Hospital has been agreed in principle, we must drive the process forward and a memorandum will, therefore, go before Cabinet. If it proceeds on the 150 acre site, it will be a separate entity from the proposed jail, with a separate entrance, road and address. It will remain the responsibility of the Department of Health and Children and will have no connection with the Department of Justice, Equality and Law Reform. A new governance structure has also been proposed for the Central Mental Hospital.
I have discussed the concerns raised with some of those who voiced them and explained what I am trying to do. In an ideal world, one would probably pick another site. However, any location selected for a new Central Mental Hospital would create difficulties and planning problems. We do not live in an ideal world and I must deal with the reality that we have an opportunity to have a new, forensic, state-of-the-art, psychiatric mental hospital in the next few years. It would be foolish of us to pass up such a possibility.
I will meet and listen to anybody who has real concerns. Stigma, which we have discussed, is often in people’s minds. The new Central Mental Hospital will be a separate entity operated exclusively by the Department of Health and Children. I hope it will be a state-of-the-art facility.
Yesterday, I attended a meeting in Cork of psychiatric nurses who are leading management change in the psychiatric services. I was encouraged by the wonderful wisdom of the group and its appetite to drive forward psychiatric services. I hope the positive attitude I encountered will be replicated around the country. The message to emerge from the meeting was that psychiatric nurses have considerable potential to do much more in the area of mental illness. I challenged those present to contribute more because for many reasons psychiatric nurses have not achieved as much as they could have achieved. We have now embraced the concept of the multidisciplinary team, to which many Senators referred. These teams are not led by anyone and all members work together as equals. The wide range of expertise available when nurses, psychiatrists, psychologists, social workers, occupational therapists and speech therapists work together will drive forward mental health services.
In response to the question as to whether I liaise with various groups, I do so constantly and attend many meetings. The other day, I attended a large meeting on advocacy which attracted 400 people. Thankfully, as many Senators noted, we  are now speaking publicly about the good and bad aspects of our mental health services. This is an important development on which I compliment everybody concerned. Attracting 400 or 500 to a meeting to discuss mental illness is a major step forward. Dr. John Owens and Dr. Tony Bates also attended and all three of us contributed and listened to service users, one of the most important things one can do.
I thank Senator Glynn for his comments on the work being done. Senator Henry raised many issues, including the health tribunals. I agree with her comments on the unfortunate problems we have encountered in this regard. Funding to drive forward the tribunals has been available since last year. Unfortunately, due to the Government’s ongoing dispute with the Medical Defence Union, consultant psychiatrists were advised by one of their representative bodies not to apply for inclusion on the panels. The Tánaiste and Minister for Health and Children, Deputy Harney, has appealed to psychiatrists to think again. I, too, appeal to them because, unfortunately, the most vulnerable people in society will be affected by their actions. I would welcome efforts by anyone with influence to persuade consultant psychiatrists to engage in the tribunals which cannot proceed unless they are actively involved in the process. I look forward to their participation as soon as possible.
I will speak to my colleague, the Minister for Justice, Equality and Law Reform, Deputy McDowell, about the Criminal Law (Insanity) Bill 2002.
Senator Henry made a valid point on an issue of concern to me. As of this week, 80 children in Limerick had not secured a school place. Last year, Limerick experienced a particular problem when 17 schoolchildren failed to secure a place. The then Minister for Education and Science, Deputy Noel Dempsey, visited the city, called the principals of all secondary schools into a room and solved the problem following a day of discussions and negotiations. We were all under the impression the problem had been solved with the decision to allow the parents of every child transferring to second level in Limerick to list their five schools of choice but, lo and behold, it has arisen again and we now have 80 fantastic children unable to secure a school place. I agree with the Senator that this sends out all the wrong messages to the children in question and their families at this particularly sensitive time in their lives. I have already discussed the matter with the Minister for Education and Science, Deputy Hanafin. I hope it will be resolved soon and that sanity will prevail.
Senator Henry and other speakers mentioned voluntary groups. I pay tribute to all the voluntary groups with which I liaise and work, including Mental Health Ireland, Aware, GROW, Schizophrenia Ireland and Amnesty International, all of which do important work. Perhaps society should be challenged more by what these organisations do.
 Each of us could do more to help vulnerable people with mental illnesses, especially those who are homeless, by “adopting” them. On my visits to psychiatric institutions and community care facilities, I often ask the nurses and carers whether the patients have any visitors. It seems there are some who never do. I visited an institution some days ago in which a chronically ill male patient, aged 79, lay dying alone in his room. He was looked after fantastically but the nurses told me he had not received a visitor for years. In view of the vast wealth now enjoyed by this country, it is difficult to believe that such people are forgotten. There is a message here for us all. Many users of the mental health services simply want somebody with whom to talk and listen. Ensuring this need is met would be helpful.
Senators Feeney and Henry contributed positively, as always, to the discussion. I thank Senator Feighan for his positive remarks on the progress being made and acknowledge his points regarding the debilitating scourge of depression in society. The expert group is considering alter native treatment methods for mental illness sufferers. It is a question of fitness of both mind and body.
I do not have time to respond to all the points made but will bear them in mind. I thank all Senators for their contributions. It is indicative of our maturity that such a useful discussion has been had on the subject of mental illness. I appreciate the help Senators give me in attempting to drive this agenda forward. I acknowledge there are problems in the services for the mentally ill as a consequence of the historical lack of priority afforded to the area. However, there is now a recognition of the importance of such services and, working together, we can ensure people receive the treatment and support to which they are entitled.
An Leas-Chathaoirleach An Leas-Chathaoirleach
An Leas-Chathaoirleach: When is it proposed to sit again?
Mr. Moylan Mr. Moylan
Mr. Moylan: Next Tuesday at 2 p.m.
The Seanad adjourned at 1.35 p.m. until 2 p.m. on Tuesday, 22 February 2005.
Seanad Éireann 179 Mental Health Commission Annual Report 2003: Statements.