Mary Butler (Waterford, Fianna Fail)
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I move: "That the Bill be now read a Second Time."

As Minister of State for mental health and older people, I am pleased to introduce the Mental Health Bill to the House. The Bill has been long in gestation. A commitment to review the Mental Health Act 2001 “informed by human rights standards and in consultation with service users, carers and other stakeholders” was committed to by the current and previous Governments. The review of the Mental Health Act and the development of a new Bill have featured in successive programmes for Government and are long-standing priorities for me and my Department. The Bill is also a priority under Sharing the Vision and Sláintecare.

While the 2001 Act was robust, progressive legislation for its time, the delivery of mental health services has progressed significantly since that time. The 2001 Act does not fully reflect our current approach to mental health services, such as the shift towards community-based services, the adoption of a recovery approach in service delivery and the importance of listening to people with lived and living experience of mental health services in the development of those services.

Ireland ratified the UN Convention on the Rights of Persons with Disabilities, CPRD, in February 2018, and the convention's rights-based approach to disability was considered when drafting the Bill. It is worth noting that, at the point of ratification, Ireland included a declaration to the effect that it believed involuntary admission and treatment for mental disorders to be in keeping with its understanding of the convention, subject to adequate legal safeguards being in place.

The Bill comprises seven Parts and 202 sections. This is a lengthy Bill containing a number of complex legal and ethical considerations. It deserved and needed a number of years to bring it to fruition. The progression of the Bill has been one of my key priorities during my time in office and I am truly delighted to present it today. Key to developing the Bill was the extensive consultation with key stakeholders. I thank each of the organisations and individuals involved for their input, including the HSE, the Mental Health Commission, the College of Psychiatrists of Ireland, Mental Health Reform, members of which are in the Gallery, the Ombudsman for Children, and key professional groups such as the Nursing and Midwifery Board of Ireland, the Irish Psychological Society and the Irish Association of Social Workers.

In 2021, I launched the public consultation, which received 100 submissions and helped inform the development of the Bill. I thank each person and group who submitted to that consultation, especially people who shared their own experiences and those of their loved ones during the drafting the Bill. I also express my sincere thanks to my colleagues across the Government, the members of the Oireachtas Sub-Committee on Mental Health and the committee secretariat for their work on the pre-legislative scrutiny process. Furthermore, I commend the Trojan work of the officials from the Attorney General’s office, the Office of the Parliamentary Counsel and my Department in readying the Bill for publication and for their continued work in preparing the Bill for Committee Stage.

In terms of the most significant provisions, I highlight the following. The Bill contains a revised approach to involuntary admission and detention, updated criteria for detention, additional safeguards to protect involuntarily admitted people and new consent to treatment provisions closer in alignment to the Assisted Decision-Making (Capacity) Acts. It expands the Mental Health Commission’s regulatory functions to include the regulation, registration, and inspection of all mental health services, including community residences and services and all community child and adolescent mental health services, CAMHS. It includes a new, stand-alone Part which relates solely to the inpatient care and treatment of children and, subject to certain limited exceptions, will allow 16- and 17-year-olds to consent to or refuse treatment on the same basis as consent and refusal for physical health.

A section-by-section summary of the Bill can be found in the accompanying explanatory memorandum. I will briefly outline some of the important features of each Part of the Bill.

Part 1 deals with the preliminary and general provisions of the Act, including the Short Title, definitions, regulations and legislation to be repealed on the commencement of the Act.

Section 2 of Part 1 provides for a number of changes to the definitions in the Bill. These include that references to "patient" have been replaced with "person" throughout the Bill; an updated, expanded definition of treatment, which includes ancillary tests; and a new definition of the term "mental disorder", which includes the decoupling of mental disorder from the criteria for detention. Furthermore, it will no longer be possible to involuntarily detain someone purely because they have a significant intellectual disability or a mental disorder that does not meet the criteria for detention.

Part 2, in sections 9 and 10, deals with the guiding principles to apply for adults and children, respectively. The guiding principles for adults will replace the existing best interests principle for adults and move towards a system in which people are encouraged and supported to make decisions about their care and treatment insofar as possible.

In the context of adults, the Bill will help shift our mental health legislation towards a greater focus on the autonomy of the person. The guiding principles broadly reflect the principles of the Mental Health (Amendment) Act 2018, a Private Members’ Bill introduced by our colleague, the Minister of State, Deputy James Browne, in the previous Dáil. Best interests will remain the primary consideration for children, in line with Article 3 of the UN Convention on the Rights of the Child.

Part 3 deals with involuntary admission and is split into four Chapters. These Chapters set out the involuntary application and admission process for the 2,666 registered inpatient beds in the 66 approved centres, which will be known as registered acute mental health centres under the new Bill. Chapter 1 of Part 3 sets out the involuntary admission process, including the criteria for detention and the three-step process for admission and renewal of these orders. Section 12 deals with criteria for involuntary admission and updates the criteria for involuntary admission. The criteria are one of the most important aspects of the Bill and a lot of time was spent getting the balance right between autonomy and treatment. The criteria in the Bill have changed from the general scheme. There are two reasons for this, namely, to ensure the criteria would not be set so high as to be inoperable and to ensure the Bill did not create a legal loophole where people could discharge themselves early if they refused all forms of treatment. To address these issues, the Bill keeps separate grounds for admission on risk grounds and treatment grounds. For detention on risk grounds, the admission must benefit the person’s condition or reduce the risk he or she poses. For detention on treatment grounds, there must be an immediate need for the person to receive treatment.

Sections 13 and 14 deal with applications for involuntary admission, providing for an expanded role for authorised officers to make an application for involuntary admission, in line with the current programme for Government. The Bill allows for applications to be made by authorised officers or, in a change from the general scheme, by family members or healthcare workers. The Bill no longer allows members of An Garda Síochána to make applications, although they may still take people into custody.

As noted in the Mental Health Commission’s annual report, there were 1,951 admission orders from the community in 2023, of which 32% were made by members of An Garda Síochána. This will no longer be possible under the new Bill. The HSE will be required to ensure availability of authorised officers across the country. In 2023, the HSE reported there were 211 staff members trained as authorised officers, up from 126 in 2022. Officials in my Department will work with the HSE to continue development in this regard ahead of commencement of this legislation. This Chapter also includes sections on Garda powers to take people into custody and the mandatory provision of information to people when they are detained.

Chapter 2 of Part 3 provides for the review of each involuntary admission under the Bill by an independent body. This is a vital safeguard when a person is deprived of his or her liberty. Each admission will be reviewed within 21 days by a mental health review board. These are currently known as tribunals. An independent examination of the person will be carried out by a consultant psychiatrist and a psychosocial report will be prepared by a nurse or an allied health professional before each review board meets.

There were 3,638 orders for mental health tribunal hearings in 2023, with approximately 48% going to hearing and approximately 52% of orders revoked prior to the hearing taking place. These tribunals, or review boards as they will be known under the new Bill, play a key role in vindicating the rights of people who are involuntarily admitted. Even though they relate to only a small percentage of people, they are some of the most vulnerable in our society who need our help and support. This Chapter also includes provisions on appealing a detention to the Circuit Court, transfer of people to other hospitals, including the Central Mental Hospital, discharges, absences and the power to detain a voluntarily admitted person for a limited period.

Chapter 3 of Part 3 relates to consent to treatment for involuntarily admitted persons. Under the existing Act, a person can only be treated without consent if he or she is incapable of doing so. The Assisted Decision-Making (Capacity) Act 2015 was commenced last year. It is important the capacity and decision-making rights of people detained under the Mental Health Act are aligned as closely as possible with the rights of the general public. The assessment of capacity in this Bill is aligned with the assessment of capacity in the Assisted Decision-Making (Capacity) Act 2015. If the person lacks capacity, an application can be made to the Circuit Court to put in place a decision-making order or representative. These supports are vital to vulnerable individuals who might otherwise struggle to make decisions for themselves.

The Bill provides for treatment to be given without consent in some circumstances. For example, while a capacity assessment process is under way or when awaiting a decision from the court, treatment can be given to people in limited circumstances, or, subject to strict criteria, an application can be made to the High Court for involuntary treatment.

Chapter 4 of Part 3 deals with restrictive practices for adults and sets out the robust legal framework in which restrictive practices can be applied. The 2001 Act has very limited safeguards in this regard, so this Bill brings many of the safeguards in the commission’s rules into primary legislation. Each use of seclusion or restraint must only be used as a method of last resort, for as short a duration as possible and proportionate to the level of risk. I note the positive downward trend in the use of restrictive practices in recent years and I expect to see this trend continue towards a zero-seclusion, zero-restraint policy, as advocated in Sharing the Vision.

Part 4 provides for a new, stand-alone Part related to the care and treatment of children in mental health services and is broken down into four Chapters. Chapter 1 of Part 4 sets out interpretation for this Part and interaction between the Mental Health Bill 2024 and the Child Care Act 1991. The Bill will continue to cross-reference the Child Care Act 1991. This will ensure children in court for mental health proceedings and childcare proceedings will continue to be treated equally and have access to the same safeguards.

Chapter 2 of Part 4 deals with admission of children to registered centres. It creates different categories of admission for children based on age and capacity. For example, children over 16 years of age can consent to their admission if they have the capacity to do so. For children under 16 or those over 16 who lack capacity, a parent or guardian can consent to their admission. Involuntary admission by way of application to the District Court will continue to be available where a parent or child refuses to consent to admission. This Chapter also provides for the criteria for involuntary admission; appeals to Circuit Court; the renewal and discharge of involuntary admission orders and power to detain a voluntarily admitted child who fulfils the criteria for involuntary admission; the powers of An Garda Síochána to take a child into custody; provision of information to children; and absences from a registered acute mental health centre.

Chapter 3 of Part 4 deals with consent to treatment for children, including obtaining consent for treatment from the child or a parent or guardian and related matters. It also provides for applications to be made to the High Court for involuntary treatment orders subject to strict criteria. It states that electroconvulsive therapy, ECT, cannot be administered to a child without approval of the High Court.

Chapter 4 of Part 4 sets out the circumstances for the limited use of restrictive practices for children, with all of the protections for adults applying to children as well as additional protections on notifying the role of parents and guardians of their use.

Part 5 deals with the Mental Health Commission and is broken down into six Chapters which deal with the continuance and functions of the commission, membership, functions, committees, meetings and remuneration of its board, the chief executive officer and his or her functions and the staff of the commission. This Part also sets out the responsibilities of the commission regarding accountability, including its strategic plan, annual business plan, annual reports, accountability of the chief executive officer to Oireachtas committees and prohibition of unauthorised disclosure of confidential information.

The final Chapter of Part 5 deals with the inspector, inspections and inquiries. It sets out the functions, powers and duties of the inspector and assistant inspectors and the provision of the chief inspector’s annual review and inspection reports.

Part 6 deals with the regulation of mental health services and is broken down into six Chapters which will be commenced on a phased basis. This Part provides for the commission to regulate, register and inspect all mental health services in the State, including all community mental health services. The regulation of these services will be introduced on a phased basis following enactment of this legislation. The Part sets out details related to the registration and renewal of registration for all services.

It also sets includes details on disciplinary actions, such as the suspension and revoking of registrations, or adding conditions to a service’s registration where it is non-compliant with the legislation or regulations. The Bill introduces compliance notices, which will allow the commission to improve services’ compliance with statutory obligations.

This Part also sets out provisions related to the various people in charge of services, provisions related to closure, cancellation of registration and taking charge of a service by the HSE.

Part 7 comprises 6 chapters setting out the various miscellaneous provisions of the Act, such as codes of practice, electronic signatures, data protection and regulation-of-care plans for adults and children in registered centres. It also provides the legal basis for record-keeping, provisions related to offences and penalties under the Bill and legal aid to involuntarily admitted people. This Part includes two amendments. The first is to section 23 of the Non-Fatal Offences Against the Person Act 1997. It amends that section to allow children aged 16 and 17 years of age to consent to treatment for mental health on the same basis as physical health. The second amendment is to sections 85(7) and 136 of the Assisted Decision-Making (Capacity) Act 2015 to remove the exclusion of certain involuntarily detained people from accessing the provisions of that Act.

Finally, Part 7 also allows people to select a nominated person to receive information on their behalf and with whom they can consult during their admission, such as with decisions regarding treatment or during discharge planning. This particular provision has the dual function of allowing a person to access advocacy supports, either personal or professional, and put in place a formalised pathway for family to be involved in a person’s care and treatment more directly, where the person concerned consents. With regard to costs to enact the Bill, my Department continues to work closely with relevant interdepartmental counterparts to ensure that both capital and current costs associated with this Bill are aligned to implementation timelines associated with the planned commencement of the Bill. It is recognised that any costs arising will be subject to prioritisation against other competing demands as part of the annual Estimates process for the relevant year. In the interim, my Department will continue to proactively engage with the HSE and the Mental Health Commission to assess the totality of the associated costs arising from the Bill.

This Bill has been many years in the making and I believe sets out a robust framework for provision of our mental health services in the years to come. I expect the Bill will be discussed in depth on Committee Stage and I look forward to debating amendments tabled by the Government and Opposition during that process. I believe it is the aim of all Deputies gathered here today to ensure this legislation is as comprehensive as possible. I look forward to working with all Oireachtas colleagues and all amendments tabled will be given due consideration.

This is vitally important legislation. It has the potential to transform many aspects of our mental health services to make it person-centred, human-rights based and lead to significant improvements to services through enhanced regulation. I look forward to an informed, positive and constructive debate on the Bill and I am happy to commend the Bill to the House.

Mark Ward (Dublin Mid West, Sinn Fein)
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While I acknowledge and welcome the publication of this Bill and recognise the hard work done by the Minister of State, and her officials to get to this stage, it is long overdue. A general scheme of this legislation was approved in 2015 but was not produced until 2021. I was a member of the Sub-Committee on Mental Health that did the pre-legislative scrutiny of the Bill in November 2021. We concluded in April 2022 with 19 recommendations. This Bill was not published until July 2024. In simple terms, what this means is that it is unlikely that this Bill will pass through the Houses of the Oireachtas in the lifetime of this Government. It is another example of the lack of urgency by Government to tackle the crisis in mental health services. Today I give a commitment that a Sinn Féin-led Government would prioritise this Bill after the upcoming elections, which cannot come soon enough. Sinn Féin would put in place robust, person-centric mental health legislation that would protect the rights of people with mental health difficulties in the decades ahead.

Even though the Government has left this legislation way too late to enact, there are things that can be done right now that will improve people's experiences of mental health services. You do not have to believe me when I say there are problems in child and adolescent mental health services, CAMHS. Independent reports by the Mental Health Commission and Dr. Seán Maskey have highlighted the issues. These include children lost to follow-up, lack of monitoring of psychiatric medications, unacceptable waiting times for high-risk referrals and many other operational issues. In February, Sinn Féin introduced legislation to amend the Mental Health Act 2021 to allow the Mental Health Commission to regulate CAMHS. The Government kicked this down the road until November. The Government can introduce this right now. This would safeguard children and lead to better mental health outcomes.

I did a bit of research for this debate and I came across a parliamentary question submitted to the Minister of State by the Minister of State, Deputy Emer Higgins, asking for an update on my with legislation to regulate CAMHS. While I thank Deputy Higgins for taking a keen interest in my work, I was a bit bemused by the Minister of State's response to her, which stated, "The Government proposed a nine-month timed amendment to the Bill to allow for issues contained in the Bill to be further examined in consultation with Deputies Ward and Cullinane".

I can certainly say that I have not been consulted on this up to date. I spoke to Deputy Cullinane and neither has he been consulted to date. I was not aware that the Minister of State needed to consult me or Deputy Cullinane on this matter. My understanding is that my legislation will pass in November without debate, so why is there a need to consult with me on this? Does the Bill that I have not go directly to Committee Stage in November? That is what has happened before. I would like clarification on the response the Minister of State gave to the Minister of State, Deputy Higgins, as I believe it to be factually untrue.

There seems to be no intention by Government to safeguard some of the most vulnerable children in the State. Under this Government, we have seen waiting lists for CAMHS spiral upwards. There's been an 80% increase in the number of children waiting for first-time appointments since the Government took office. The number of children waiting for more than a year for first-time appointments is up by 140%. Children are being denied the opportunity to reach their full potential. Sinn Féin would increase the capacity in CAMHS so that no child would be left behind. Some 75% of mental health conditions are established by the age of 25, but young people between the ages of 18 to 25 are not specifically targeted by early intervention and they are not targeted in this bill. Sinn Féin would address this by introducing a new child and youth mental health service that would eventually replace CAMHS. This would stop young people falling off the cliff edge at the age of 18 and ensure the continuity of care.

This Bill does not legislate to ban admitting children to adult inpatient psychiatric wards. I acknowledge the reduction in the number of times this has happened recently and the Minister of State's attention to this issue, because we can see the numbers have decreased. However, we now have a chance to be ambitious. Today, we can put down a marker that says we will have zero tolerance of any child being admitted to an adult psychiatric facility.

The Children's Rights Alliance has given the Government and E grade on performance for allowing this to continue. Its report noted that children were admitted to adult psychiatric units in Ireland because only 51 of the 72 CAMHS inpatient beds were operational. This legislation should be based on children's rights and not the lack of investment in children's mental health care. Sinn Féin wants to set the bar high in this regard. We want legislation to ban this practice and to ensure that children are treated with dignity and guaranteed safe environments. We should be aiming for zero tolerance and this can be achieved by funding services and providing a safe level of staffing. The decision by the Government not to include the prohibition of children being placed in adult psychiatric facilities means that it has accepted defeat and has stopped trying to prevent it.

One of the recommendations made by the Sub-Committee on Mental Health was in relation to the use of language. I acknowledge the change of terminology from "patient" to "person", which is very welcome. Recommendation 2 states:

The Sub-Committee recommends that the General Scheme be amended to remove the reference to the term 'mental disorder' and replace it with 'persons with psycho-social disabilities' in line with the UNCRPD and the social model of disability.

On reading this Bill, I found that the words "mental disorder" appear 41 times. This is something the Government could work on easily and make the Bill more human-rights compliant. It has been two years since the committee made this recommendation but the Government seems to have failed to act up to now.

There is also no independent complaints mechanism in the Bill. We need such a mechanism so that people can make complaints in the certainty that their care will not be negatively impacted. At the moment, what we have is the HSE investigating complaints about itself.

People do not have confidence in this method. An independent complaints mechanism was called for by human rights groups and is in line with international best practice. Recommendation 19 of the Sub-Committee on Mental Health was the establishment of an independent, fully-funded and resourced independent complaints mechanism for mental health services. There is no other cohort accessing health treatment where people may be denied their liberty.

I welcome the changes in Bill on involuntary admissions to psychiatric facilities. For too long, members of the Garda have been the gatekeepers in mental health. The Bill moves towards allowing HSE authorised officers, usually psychiatric nurses, social workers or occupational therapists among others, to issue involuntary admission orders. There has been an increase in authorised officers hired by the HSE. The Minister of State mentioned this and it is something I welcome. However, they need to be available across the entire State in order that there is no postcode lottery of care. We also need certainty about the numbers needed and the numbers available. At present, the HSE target for authorised officers is four per 100,000 of the population. Will this target be revisited as we move away from involuntary detentions by An Garda Síochána and towards authorised officers? Will authorised officers be included in the crisis de-escalation team pilot project that is due to start in Limerick in the coming months? The Irish Council for Civil Liberties has concerns about the standards of safeguards to ensure that involuntary admissions are only used in emergency situations with regard to the role of An Garda Síochána in the process. I would also like this to be examined. Sinn Féin will not oppose the legislation on this Stage but we will table a raft of amendments on Committee Stage which need to be passed.

In my remaining time, I will talk about what we would do in government and what we would include in this Bill. Having spent years working in front-line addiction and mental health services, I know the importance of people getting the right care in the right place at the right time. Where a person lives and their ability to pay should not be a barrier to accessing mental health care. I have had comprehensive engagement with mental health stakeholders from the HSE, the community and voluntary sector, international experts and people with lived experience to produce our mental health policy documents. Sinn Féin’s mental health action plan would transform how we deliver mental health services across the country. It sets out our absolute commitment to deliver widespread and significant change and a fresh start to mental healthcare. Our plan is based on fairness, access to high-quality local services, early intervention, prevention and suicide reduction. We would ensure that mental health is an all-of-government priority. The big difference between Sinn Féin’s plan and the approach of Fianna Fáil and Fine Gael is that we would move away from decades of crisis management and underinvestment to community-based proactive care backed by multi-annual funding, long-term planning and workforce planning. The Government has paid lip service to mental health. The result is that mental health services are in a state of emergency. Funding has been stagnant, reform has stalled and waiting lists have reached a crisis point. The HSE recruitment embargoes and a lack of strategic workforce planning at Government level have left mental health teams understaffed across the country with devastating consequences. Investment in mental health and well-being is a no-brainer.

Maurice Quinlivan (Limerick City, Sinn Fein)
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At the outset, I acknowledge that in the main, the Bill is positive. It is encouraging to see the Government adopt many of the recommendations of the expert review group. The Bill is a positive advancement in supporting those with mental health challenges. However the delay in publishing the Bill is disappointing. The Government had four years to produce a Bill. To do so in the last weeks or months of its term means that its provisions will not be enacted in the lifetime of the Government.

Two years after the pre-legislative scrutiny, we are only getting to debate the Bill now. That is not good enough for those who suffer with mental health challenges and were expecting more. Unfortunately, under this Government, mental health is not treated as a priority. If mental health was a priority we would have had the Bill enacted. The trial 24-7 de-escalation unit in Limerick that my colleague, Deputy Ward, mentioned would be already operational. It was due to be operational in quarter 4 of 2022 but has faced delay upon delay and is still not operational. It baffles me that over two years on, this service has still not been rolled out. It is an out-of-hours service and, as we know, the challenges of mental health do not operate to a schedule. The trial in the North proved successful with many people being treated and diverted from emergency departments. We know that anything that can be done to divert people from going to the emergency department in Limerick would be very welcome.

For too long, mental health has been treated as a mere tack-on to more general health. For too long, waiting lists, particularly for children and adolescents have been moving in the wrong direction. One must look at the child and adolescent mental health services and the wait times since this Government took over. In the CHO that covers the area of Limerick, Clare and north Tipperary, when the Government took over there were 196 people waiting to be seen by CAMHS. Fast forward to May 2024, CHO 3 has 234 people waiting to be seen. The psychology services in CAMHS have seen a dramatic increase in the number waiting for treatment. In CHO 3, there were 525 children waiting in December 2020. In February 2024 there were 776 children waiting for treatment. Every expert in child and adult mental health will say that early intervention is vital to avoid enduring and worsening problems in the future, yet these figures reveal that if a child or young person seeks out care, he or she will likely face extensive waiting periods that are simply unacceptable and which put that person and his or her mental health at serious risk. The children on mental health waiting lists have waited long enough. The approach to mental health needs to change. While children await appointments, their childhoods are being damaged.

What Sinn Féin would do differently to this Bill is in our mental health action plan. It outlines what we would do to support those with mental health challenges. That includes universal counselling, primary care, State-wide access to integrated mental health and well-being community services, the delivery of 47 additional community CAMHS teams and 41 inpatient community CAMHS beds and crucially, the roll-out of a full emergency department self-harm and suicide reduction programme.

The Bill is a positive step but more needs to be done. I hope that the upcoming budget offers significant resources to those supporting those in need. Mental Health Reform, in its lobby emails that I am sure every single TD in the Chamber has received, has called for an investment of an additional €120 million in our mental health services in the upcoming budget, with €40 million to maintain existing services and €80 million to be used exclusively to develop new and improved mental health services. This is a fair call which is supported by research. I am sure that many families would be waiting to see if this ambition is matched by the Government.

Before I finish, I want to commend and express my gratitude to all the huge number of volunteer groups which work in Limerick. They are going into the bearna bhaoil where the Government has failed. It is very depressing when you live in Limerick to hear the helicopter overhead. Suicide can be very public. I want to commend some of the volunteer groups such as Limerick Suicide Watch and Limerick Treaty Suicide Prevention, which patrol the river banks, the Haven Hub and Limerick Land Search. I attended their new premises last week, which it has attained through voluntary contributions. It is not yet complete and it is looking for extra money. These volunteers step into the gap where other services do not exist, along with a large number of other groups which I did not have the chance to mention.

Pa Daly (Kerry, Sinn Fein)
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Before I mention CAMHS and aspects of the Bill, I wish to raise the situation regarding the Ocean View nursing home in Camp, County Kerry. I attended a briefing by the Irish Nurses and Midwives Organisation earlier. One of the calls in its pre-budget submission was the operation and delivery of long-term care and to reverse the privatisation of long-term care.

As the Minister of State may be aware, the situation in Ocean View is that its registration has been revoked by the HSE-----

Mary Butler (Waterford, Fianna Fail)
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By HIQA.

Pa Daly (Kerry, Sinn Fein)
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By HIQA, and the HSE has now come in and is the current provider of care. HIQA did commend Theresa Winter and all her staff for providing first-rate care for the residents there. All the staff in that nursing home are directly employed by the HSE now. The families have received letters. I have a copy of one here which says that it was necessary to make alternative arrangements for the residents who have been there. One has been there for more than 20 years. Think of the disruption. I attended a meeting yesterday with families and the staff there. There are 51 staff in that nursing home. It was quite emotional at times and the uncertainty they are facing is very distressing. Of course, regulation by HIQA is necessary and must be enforced but the HSE has accepted that Ocean View has been a very happy home for all these residents. I am asking the Government, through the Minister of State, to end the uncertainty for families and to pause these transfers and do everything possible to, as the INMO said, reverse the privatisation of long-term care. This is an opportunity to provide long-term care in the west Kerry area, not only for the 25 residents there but also the 34 who were there until the beginning of this year, for example. It is an ideal opportunity to expand services. I will be meeting the HSE in the morning to try to make that happen and to provide the extra care in that community.

That leads me in to my next point because if Ocean View is closed it will put extra pressure on the beds in University Hospital Kerry and beds in other nursing homes around the county. What is happening with the supposed lifting of the recruitment embargo? It clearly has not been lifted and there are problems. Recruiters in University Hospital Kerry are being asked to identify five priority posts. They cannot recruit any support staff, ward clerks or porters. Occupational therapists are working at 37% of capacity, physios at 50% and it is no wonder some of them are being tempted by private practice or by going to Australia. The hospital still has to work off the staffing levels of last December. It cannot expand and is stuck in a rut.

On the CAMHS issue, the Minister of State is aware of the over-medication, the mistreatment of patients, the Maskey report and all of that. Still, where families have received apologies, the redress scheme has not been expanded to provide those families with money so that they can take the case. The expense is being piled upon the injustice they have already suffered. I am asking the Minister of State to address that as soon as possible because it is totally unfair for those families. They have come forward and have been brave but they need to seek the redress as soon as possible.

Rose Conway-Walsh (Mayo, Sinn Fein)
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While I welcome this Bill and the vital and long-overdue protections it will help to guarantee for citizens of the State, I despair at the snail's pace of progress on reform in mental health services, and even more crucially, on the provision of those services for those people who need them. As I was sitting here, I was imagining if previous Governments had really resourced A Vision for Change and put the resources and what was needed behind it, where we would be now.

In February this year, Sinn Féin tabled legislation which would have introduced many of the reforms contained within this Bill. However, it was not supported by the Government at the time. I commend my colleague, Deputy Ward, who has done so much work in this area. While I welcome CAMHS being brought under the regulation of the Mental Health Commission, there are areas on which the Bill is not strong enough and aspects such as failure to include an explicit ban on the admission of children into adult psychiatric units. We have already heard the harrowing testimony over recent weeks regarding the abuse suffered by children in the State in school settings. We should be going and above to ensure our vulnerable children are protected in law to the highest standards possible. This Bill fails to do that. However, as Deputy Ward said, we will be putting amendments into the Bill to make it better.

The level of provision of mental health services by the Government continues to fail those who need it. Just as we are speaking on this, it also fails those who are working in the services. Earlier this week, members of the Psychiatric Nurses Association of Ireland in my own county of Mayo, and in Galway, Roscommon and the CHO 2 area, have been forced to initiate industrial action over the staff shortages and the knock-on effects on services. It is unbelievable that the HSE is refusing to recruit all new graduate nurses. Only half of the required psychiatric nurse graduates for the area have been recruited. Meanwhile, we have 825 people waiting more than 52 weeks in the CHO 2 area for psychology. We have 236 people waiting for CAMHS. Why are permanent contracts not being offered to these nurses? While the Government might say the recruitment ban is lifted, it has not been lifted in Mayo or in the CHO 2 area. There are too many positions that are still vacant and too many nurses and qualified people in our health services going abroad each year to provide mental health services in other countries. How many of them would stay if they were given permanent contracts? The general secretary of the PNA said that around 10% of psychiatric nurses are leaving Ireland each year. I ask the Minister of State and the Minister of Health to urgently intervene to resolve the industrial action there and to address the chronic understaffing in all of those three counties.

Duncan Smith (Dublin Fingal, Labour)
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It feels like an overdue relief that this Bill has finally made it to the floor of the Dáil. It is long overdue and it has been a long road to get here and rightfully there are concerns from all of us as to whether this legislation can be progressed in however long left there is left in the lifetime of this Government. To make it the first key legislation to be discussed after the recess is a good step and hopefully we can all get to work through Second Stage and into Committee Stage, to put our amendments through and see this Bill in, hopefully an amended form, but become law in the not-too-distant future.

There is a lot of good in this Bill. The introduction of a nominated person to be someone's advocate is welcome. Those who are going through mental health issues often find it difficult to advocate for themselves especially in those moments when they really need to. Therefore, this will be a very real and impactful change for many people. The changes around involuntary admission are also really important and hopefully will be a start to addressing our need to separate mental health difficulties from criminal justice issues. There is still such a stigma around mental health and the links people have been making between mental health difficulties and criminal activity has only further inflamed that stigma, which has real-world implications for many people. It is also important to welcome that this Bill puts time limits on how long a person should have to wait before an authorised officer sees him or her to make an application recommending involuntary admission. People in distress cannot and should not be left indefinitely for someone to treat them but I have concerns in how we will ensure this does not happen even when the legislation is in place in regard to the resources and staffing, which I will touch upon later. However, it is important we see the intent included in this legislation.

The regulation of mental health services introduced in this Bill is also important moving forward. It is something I and colleagues across the Chamber have been calling for and its implementation will be vital. Of course, we have a huge issue due to the lack of regulation and the issue of overmedicating and undermedicating. The Maskey report states as much, with significant harm being caused to 46 children because of overprescribing by a junior doctor. Overmedication is extremely dangerous and can have lifelong damage. One case of this was so extreme that a young man who was overmedicated by the north Kerry CAMHS had to undergo surgery because of the impact on his body. Therefore, to see regulations finally introduced is welcome and we need to make sure they are thorough and efficient.

We believe provisions need to be added to this Bill as it moves forward. I take the opportunity to highlight the work of Mental Health Reform, which has been dogged, diligent and committed in advocating for a robust mental health Bill for the entire lifetime of this Dáil in which I have been a Member and beforehand. I support its views on a number of aspects of the Bill as it is written and presented before the House, starting with its concerns regarding the provision for An Garda Síochána to take people into custody without proper safeguards. At present, during a mental health crisis individuals are directed to present at their nearest accident and emergency department, go to their GP or utilise services such as the crisis resolution service. However, the issue arises over the lack of being able to distinguish between risk to self and the risk to others. This speaks further to a point about the stigma around mental health difficulties and the conflation that happens in regard to acts. We need to see risk to self and risk to others clearly separated and additional safeguards must be put in place to address concerns. We want to see people being brought to relevant healthcare facilities where medical professionals can de-escalate a situation and begin a process for admission, if that is what is required. This is what professionals are trained for and judicial custody is not an environment that is conducive to de-escalation or improved mental health. As Mental Health Reform points out, members of An Garda Síochána have previously raised concern over this stating “stations are not places for mental health patients”.

In regard to advocates, which I have welcomed, I agree with Mental Health Reform's position that there is still a need to reference the right to an independent advocate. This is such an important part of the legislation and it does not make sense to me to unintentionally have people disenfranchised as it is those most marginalised who may not have close family members or outside supporters and who would be in need of an independent advocate. The obligation on the State to provide a statutory right to an independent advocate is required.

In the amendments to this Bill, we need to see an explicit prohibition on admitting children into adult psychiatric units. This is an absolute necessity and budgetary reasons cannot be put forward as the reason children continue to be admitted to these units. I acknowledge that simply having something in law does not mean that the practice will no longer happen, as we have seen with the assessment of needs statutory limits, for example. However, if nothing else, we need to see this as a starting point to ensure further improvements happen as soon as possible and further resources are put in to ensure our children are not admitted to adult psychiatric wards.

The Labour Party also supports the call for the inclusion of an independent complaints mechanism. It is common sense that sometimes people are nervous about making complaints directly to the place where they have also been receiving treatment.

As has, unfortunately, been seen, sometimes there is the need for a complaint. Removing barriers such that people will feel safe to make one is very important.

I would like the Government to examine the review timeframe of ten years, which is far higher than the usual five-year review. We should not be seen to go backwards in this regard from the 2001 Act, which was supposed to be reviewed five years after its commencement.

As I said, the Bill is welcome, but it needs to be seen as a good starting point and is not the finished article, as far as we are concerned. In its current form, it will not be robust enough to see us through the next decade and beyond. More widely, I emphasise our responsibility as elected representatives to lead the way on removing the stigma that remains around mental health, especially for young people. There has been a huge increase over recent years in the number of social media influencers who target young men and frame mental health difficulties as something to be ashamed of or something that could be fixed if they just either went to the gym or made their bed. We need to push back on this narrative. Mental health difficulties are not only as they are portrayed on TV and we need to lead with empathy, not judgment. It is important to be consistent to ensure nobody will be left behind by the services this country provides.

Sadly, even with this legislation, people are being left behind, and it is those people, particularly those with autism, who have been and continue to be forgotten. This is an issue I raised earlier this year in regard to CAMHS. The system is failing autistic children. The CAMHS operational guidelines set out that admission to services can be refused to autistic children where there is an absence of a moderate to severe mental disorder. Where this is such a disorder, it is the role of CAMHS to provide appropriate multidisciplinary mental health assessment and treatment. Frequently, however, as we will all have experienced, we are just not seeing care provided, even when there is such a disorder. Many families facing this barrier feel that children with autism are being left behind by a system that feels it is easier to deny them any treatment than to pass on the responsibility to someone else and intervene with a multidisciplinary approach.

One of the biggest indicators that a state is failing in its responsibility to provide adequate medical care for its citizens is when they have to fly abroad to get it, and this continues to happen in Ireland. Members of a group called Families for Reform of CAMHS, with which I am sure most of us are familiar, have outright stated they have travelled to Spain in order that their child could get care. What does it say about us that we are letting this happen? My advice clinic deals with parents of autistic children who are simply at their wits' end trying to get their child help that other children in this country are entitled to, which they are not getting.

There is a lot of good in the Bill, as I said, but there is a lot missing, and we hope the Minister of State will be open to progressive and constructive amendments. On a broader point, we have heard that the recruitment embargo has been lifted across the health service but the reality is the opposite. In a wide range of services, from mental health services to acute care, primary care and social work, vacancies are unfilled. The recruitment embargo is continuing to exist in reality even though it has, apparently, been lifted. It is an absolute scandal, when the Government is tripping over itself trying to decide how to spend the many billions of euro it continues to find either down the back of the couch, through unexpected tax intakes or through the Apple money, that we are not really lifting the recruitment embargo and hiring the front-line health service staff and the supporting staff who help them do the jobs for which they are needed in Ireland today. The Government, and every Minister and Minister of State in the health brief, need to be honest about that. This recruitment embargo is still in place in practice and needs to be lifted, and we need to start hiring people throughout our health service again.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I welcome the opportunity to examine the Bill. I thank the Minister of State, Deputy Butler, and her officials for their work on this important legislation. We in Fianna Fáil believe in the delivery of fundamental health services to the highest standard through investment, innovation and reform. We support the Bill, which will give effect to recommendations of the expert group review on mental health legislation. The key objectives are to improve the provision of mental health services and to ensure that the autonomy of those using our mental health services will be respected insofar as possible.

Members will be aware that the Mental Health Act 2001 is the key item of legislation currently in place concerning the rights of people involuntarily detained and treated in approved centres within our mental health services. The 2001 Act has provided a robust legal framework since its commencement in 2006 and was forward-thinking legislation. It no longer, however, reflects our approach to mental health services, such as the shift towards community-based services, the adoption of a recovery approach in service delivery and the involvement of service users as partners in their own care. The programme for Government committed to modernising legislation in this area and the publication of this legislation is welcome. I acknowledge the work of the Minister of State, Deputy Butler, and her officials in this regard.

As she mentioned, the Bill is extensive and complex legislation. Quite rightly, stakeholders have been consulted over an extended period since 2021. I was encouraged to see the high level of engagement, not least from service users and their families. It is crucial that we listen to service providers and the families of the service users, and ultimately to the service users themselves, to get the feedback and the necessary reforms included in legislation. Many of the provisions of the Bill are welcome, especially the updated criteria for detention and the additional safeguards to protect involuntarily admitted persons.

The Bill also updates language used for people with a mental health illness, which is welcome. It will be important, however, that funding be provided to ensure the implementation of the legislation and, crucially, a smooth roll-out of services.

While I welcome the move away from the Garda making applications, it is critical, too, that the HSE has sufficient resources and personnel available around the clock to deal with crisis situations. That is something we have heard time and again and I know that the Minister of State is well aware of it. She visited my constituency not long ago, where we met service providers, and the need for crisis intervention is crucial. While this change is welcome, it is important that it be well resourced.

It is also particularly important that adequate funding be allocated for the provision of beds in registered mental health centres. Again, a matter that arises regularly in the Chamber relates to the need to ensure we have adequate resources for those.

I pay tribute to the Minister of State for her commitment to mental health, the brief she was given, and for her ongoing work not just on this legislation but in engaging with Members of the House from all parties in her brief of mental health and older persons.

Róisín Shortall (Dublin North West, Social Democrats)
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I welcome this long-awaited Bill to replace the Mental Health Act 2001, which we in the Social Democrats are happy to support. As we know, this is important and complex legislation. It will require further scrutiny on Committee Stage, and I certainly hope that the Minister of State will be open to taking amendments, that we can work on it in a collegiate way and that we will have time to work on it. We want to see it come through as soon as possible. I am generally very encouraged by its provisions.

Mental health services currently operate in an outdated legal framework. The 2001 Act needs to be replaced by legislation that provides the basis for a genuine, human rights and person-centred approach to mental health. We always have to keep that to the fore and use it as the benchmark for any provisions in respect of mental health services, that is, whether it is taking a human rights approach and whether there is respect for the human rights of the persons concerned. Too often, the language of human rights is used and embraced by the Government but the policies and laws required to realise those rights are not. Talk is cheap, and the human rights message has got into the talk but it has to get into the practice as well. The Bill appears to represent a real change in approach and a genuine effort to address serious gaps in the current Act.

It is regrettable, however, that it has taken so long to get the legislation to this point in the Dáil. It has been 12 years since an expert group was appointed to review the 2001 Act and almost ten years since its report was published.

That 2015 report sets out 165 recommendations to update the current Act and bring Irish mental health law into line with international best practice. In July 2015, the then Government agreed to draft a new mental health Bill to incorporate the expert group's recommendations and a year later, the then Minister with responsibility for mental health, Deputy Helen McEntee, said the draft legislation would be completed by the end of 2016. However, it took until 2021 for the draft heads to be published. Even though the sub-committee on mental health published its pre-legislative scrutiny report in October 2022, it still took this Government almost two years to approve the new Bill. Those kind of delays have to say something significant about the lack of political priority which has been given to this area. I am not necessarily pointing the finger at the Minister of State, Deputy Butler, but rather at a political level over the course of a couple of Governments. I accept that the 2018 ratification of the UN Convention on the Rights of Persons with Disabilities impacted the timelines involved. The expert group's report predates ratification and the UNCRPD needed to be reflected in this Bill. I accept that. However, that is not an excuse or explanation for a decade-long delay. The UNCRPD did not come as a surprise. There was an 11-year period between agreement and ratification. We still have not even ratified the optional protocol, the very mechanism that could be used to compel this Government to uphold people's rights. I accept that since 2015, there have been some piecemeal improvements. Three amendment Acts have been enacted, although only two have been commenced. That is quite significant. Only a completely overhauled Act could make our mental health laws human rights-compliant. That is why this legislation is so important.

From the outset, I want to acknowledge the importance of the Interpretations section of the Bill. Replacing medical language such as "patient" with the term "person" is to be welcomed, along with the removal of phrases like "suffering from". However, questions remain about the continued use of the term "mental disorder". That is not in line with the terminology adopted by the UN, the UNCRPD, the WHO or the European Commission. It is welcome that the current definition of "mental disorder" would be amended to remove dementia and intellectual disabilities, but I am still not convinced about its retention. I hope we will examine that closely on Committee Stage. The Irish Human Rights and Equality Commission raised this during pre-legislative scrutiny and it was also highlighted in a 2021 human rights analysis commissioned by Mental Health Reform. While I accept that there is not consensus on the preferred replacement language, I believe there is general agreement that the term "disorder" should no longer be in use. A 2023 WHO guidance document provides alternatives such as "persons with mental health conditions", "persons using mental health services" and "persons with psycho-social disabilities". Again I am not suggesting that there is consensus around these terms either but they are generally considered less offensive or stigmatising. I appreciate that this is a tricky area to get right and that language is constantly evolving but I think we can do better than what is there.

Mary Butler (Waterford, Fianna Fail)
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I agree.

Róisín Shortall (Dublin North West, Social Democrats)
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Thank you. I would ask that you give this further consideration ahead of Committee Stage.

In respect of CAMHS, I would like to jump ahead to Part 6 of the Bill, the regulation of mental health services. I will return to other important provisions but, as the Minister of State will know, this is an issue I have been pursuing with her for some time. While I very much welcome the inclusion of community CAMHS regulation in this Bill, it is hard to understand why this was not progressed earlier via a short amendment Bill. It is over a year since the Mental Health Commission's final report and well over a year and a half since its interim report, both of which clearly recommended immediate regulation of CAMHS. In fact, it was its primary recommendation. Families for Reform of CAMHS appeared before the health committee last January and they also stated that it was their number one priority, yet it still has not happened. Given the condition of children's mental health services in this country, this delay is very regrettable. It is frankly unforgivable, in my view, that even when we had report after report into the sorry state of CAMHS, the commission still does not have the powers to intervene in community CAMHS services. I accept that root and branch reform of CAMHS will not happen overnight but this is not a new problem. The very least the Minister could have done was progress regulation. Now well over a year has been lost when the commission could have been working with CAMHS teams to develop standards and rules and address serious shortcomings in the service. This is a service relating to children, and years lost from childhoods are really never regained. In circumstances where we are talking about children with mental health issues, there has to be a real sense of urgency in respect of those services because of the damage done to those early years, which sometimes remains with the person throughout their adult life as well. Dr. Finnerty's report should have been a catalyst for change but the response should have been speedier.

Next I would like to speak to Part 2 of the Bill, the guiding principles. I welcome their inclusion and in particular the distinction between adults and children. This new Part represents a significant shift in approach and acts on a key recommendation from the expert review group. When it comes to involuntary admissions, the 2001 Act states that the best interests of the person must be the most important consideration. While the best interests test is a core principle in respect of decisions related to the care of children, as we know, it is not an appropriate assessment tool in the care of adults. I am pleased to see that the new guiding principles will replace this paternalistic model with one that presumes individuals have the capacity to make decisions about their treatment in line with the Assisted Decision-Making (Capacity) Act. During pre-legislative scrutiny, Dr. Fiona Morrissey from NUIG's centre for disability law and policy articulated the importance of this presumption. She asked how any of us would like to be treated if we found ourselves in this situation. Would we like to be listened to, supported and have our wishes and human rights respected? After all, we are all vulnerable to periods of mental distress. Dr. Morrissey also cited recent studies which found that most mental health inpatients had full or partial capacity, higher than that of physical inpatients. It is quite an interesting finding. We need to challenge our assumptions and ensure that a culture of coercion does not pervade our mental health system, as it has unfortunately so often done in the past. After all, involuntary admissions should only ever be an absolute last resort.

Returning to the guiding principles for children, I agree that the paramountcy principle should be retained for minors. However, their views should be given due weight in accordance with their age and maturity. That is why it is welcome that the will and preferences of minors receive greater recognition in this Bill and that it provides for a bespoke set of arrangements for 16- and 17-year-olds on the cusp of adulthood. This will allow older children to be involved in the conversations around their care. Furthermore, it will bring the presumption of capacity for 16- and 17-year-olds into line with physical health.

When it comes to involuntary admissions, the provisions of the Bill are certainly a significant improvement. According to the College of Psychiatrists of Ireland, just under 2,500 admissions to psychiatric units in 2020 were involuntary, of which just under 950 were admitted for the first time. Many people may find is surprising that we could still be at that kind of level in the very recent past. Clearly something is amiss and more than 60% were readmissions. This indicates a community and primary care service that is chronically underfunded and under-resourced. I will return to this point later. The revised definitions of the terms "risk" and "treatment" in respect of involuntary admission are also welcome but this matter will require greater scrutiny on Committee Stage.

When it comes to applications, the disqualification of gardaí is to be welcomed. They can still be involved in the involuntary admissions process but the Bill places greater limitations on their role. Last year, An Garda Síochána accounted for the highest number of involuntary admission applications at 32%. That is quite high and certainly of concern. However, I am aware of a number of circumstances that arose, for example, in the middle of the night, at weekends or over the Easter or Christmas period when nobody else was available to intervene except the Garda. It is easy to point the finger at the Garda, but for families that are in difficulty with a family member who has real issues, gardaí are very often the only ones available to provide help and it is important to bear that in mind. Of course, that is a significant reflection on the fact that our out-of-hours services are so abysmally poor.

People often present at a very crowded accident and emergency department where staff are under enormous pressure and, in many cases, there is no chance of the necessary help and support or even advice being available as to whom that person can turn. The Mental Health Commission has previously raised serious concerns about this practice and called for the removal of gardaí from the list of eligible applicants but there must be alternatives in terms of support and help available to people.

The Irish Council for Civil Liberties continues to have concerns about the role of gardaí and the detention provisions contained in this Bill. While I certainly agree with that in principle, very regrettably there are occasions when a Garda station is the only safe place for a person because there is nowhere else for a person with serious mental health issues to go. Again that is a very poor reflection on the lack of priority that has been given to mental health services.

As noted during pre-legislative scrutiny, Garda stations can be extremely challenging but, as I have said, very often there are no alternatives. On Committee Stage we also need to take a closer look at the role of family members in the involuntary admissions process. The Bill still allows for them to make applications for involuntary admissions. I can understand the rationale for that. However, there are mixed views about their inclusion. The expert review group stated that only authorised officers should be able to make involuntary detention applications. I can understand why many families would want this option available to them, but I believe this requires further scrutiny, not least given the risk of long-term damage to family relationships.

On a related point affecting young people, a family member can sometimes be kept entirely in the dark as to the nature of their loved one's condition. They are very worried about them. They do not know what is happening to them. They do not know what services might be available to them. Very often family members who mean very well and are very supportive of their loved one are kept in the dark completely as to what is happening. I think there needs to be some way. I totally respect patient confidentiality and all that, but very often with people who have mental health difficulties, their therapist needs to talk to the entire family. There is an issue with the complete exclusion of family.

Several other provisions will also need to be carefully teased out by the Select Committee on Health on Committee Stage. Alongside this work, we must also consider possible ambitions in this Bill which have been identified by Mental Health Reform, namely the admission of children, of course, into adult as psychiatric units which must end. The way it has to end is by providing appropriate children services. However, for that to be realised, the Government needs to commit to providing the necessary resources. The State is still only spending half of the recommended 10% of its overall health budget on mental health. Sláintecare was very clear about this. Best practice is that 10% of the overall health budget should be devoted to mental health services. As we are only at approximately half that at the moment, there is significant way to go. By comparison, the UK spends between 13% and 14% of its health budget on mental health.

Arguably recruitment has been the biggest challenge facing our health and social care services in recent years. I am not going to go there at this at this point but additional university places must be provided. More importantly, clinical placements must be provided by the HSE. Very often the lack of appropriate clinical placements for people and training is the cause of the shortage of adequately trained people. We must have that joined-up thinking between higher education and the Department of Health and the HSE.

The optional protocol is really important. The Minister of State has committed to it but we need a timeline.

My last point is about the over medicalisation of people with mental health issues. Too often services are determined and dictated by psychiatrists when it should be ensured that adequate talk therapies are available. We also need to invest in psychology in primary care and in psychotherapy. Obviously, there is an important role for medication in the treatment of persons with mental health difficulties but because talk therapies are not available and because a once-off or twice-off appointment with the psychiatrist may be the only option available, too often medication is prescribed. We need to reduce that and reduce the medicalised model of mental health services and ensure that there are adequate talk therapies. That especially applies in the case of children. I thank the Minister of State for the Bill.

Catherine Connolly (Galway West, Independent)
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The next speaker will be from People Before Profit Solidarity. I know that Members are being caught because the debate is moving quickly and I know many of them want to speak on it, so I am just going to read out the Topical Issue Matters.