Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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We welcome the Minister of State, Deputy Butler. When we adjourned, Deputy Richard O'Donoghue was in possession with five minutes remaining. He is no longer with us.

Mary Butler (Waterford, Fianna Fail)
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He was concluded.

Thomas Pringle (Donegal, Independent)
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I am grateful for the opportunity to contribute to the debate. I broadly welcome this Bill. I have a few specific concerns with the legislation, which I will detail further. First, I would like to acknowledge the fact that this is long-awaited legislation that will make an incredible difference to the lives of thousands of people in Ireland and we must not delay in ensuring it passes as soon as possible.

I would like to take this opportunity to thank all those involved in making this legislation possible, particularly organisations such as Mental Health Reform, which has done mammoth work in mental health research, in scrutinising this Bill and in ensuring that all Members are well informed about this legislation’s impact on people with mental health difficulties.

It is important that we invest in mental health. Research shows that €1 spent on mental health returns €18 to the State, yet we consistently overlook and underfund mental health. There has been a real lack of urgency by the Government to introduce this legislation and, shockingly, the overrun in health is bigger than our entire budget for mental health. During last year’s budget debate, I highlighted that the published budget document did not even allocate mental health its own section, despite the fact that both Covid-19 and Met Eireann each got their own section. This demonstrates just how troubling the Government's priorities have been.

According to Mental Health Reform, more than 15,000 people access mental health services each year and approximately 10,000 people attend accident and emergency departments due to self-harm and attempted suicide. Approximately 2,000 people are involuntarily detained each year and more than 60% of those are readmissions. One in two people in Ireland will experience a mental health difficulty, either directly or indirectly. Yet, people’s rights are treated differently when it comes to decisions around physical health treatment and decisions around mental health treatment.

I will address the language in the Bill. It consistently uses the term "mental disorder", which is not correct language. We would not refer to someone as "physically disordered". I urge the Government to amend this language in the legislation.

I welcome the fact that the Bill seeks to ensure that the voices of adults be heard and respected and that there will be a greater recognition of the will and preferences of under 18s. I also welcome that this legislation will ensure that people are supported to make their own decisions and that information must be provided to them in a way that they understand. It is vitally important that everyone has the opportunity to be an active participant in their own health care. I am glad to see that the legislation will expand the regulatory functions of the Mental Health Commission; that the commission will have a register of acute mental health centres and community mental health centres; that these centres and services will now have to apply to be registered; and that the commission will inspect community services too.

I would like to highlight section 114 of Part 5 relating to specialist advisers. People with lived experience of mental health difficulties should be mentioned here and this would be an opportunity to have people with lived experience more involved in the commission, which would ensure the commission is working in the best interests of those it supports. I welcome the additional criteria and safeguards for involuntary admission. Involuntary admission should be the very last option for treatment. I welcome the fact that the legislation puts time limits on how long a person should have to wait before an authorised officer arrives to make an application recommending him or her for involuntary admission. I highlight the recommendation from Mental Health Reform that only authorised officers should be able to make these applications so that the family relationship is protected and the responsibility is not on family members to make such a difficult decision. I am glad that gardaí will not be allowed to make applications for involuntary admissions anymore, but disappointed that there are parts of the Bill that provide that gardaí can still take people into custody without proper safeguards while they wait for an authorised officer. I do not believe the Garda particularly wants that right. It causes great difficulty for them too.

I welcome the inclusion of the right to a nominated person. However there is still a need to reference the right to an independent advocate and there is a real need for an independent complaints mechanism. This is particularly important in light of the reduced inspection frequency by the Mental Health Commission outlined in this Bill. I am sure everyone in this Chamber agrees that CAMHS needs a complete overhaul. Constituents in Donegal have told me that they are waiting more than a year on the CAMHS waiting list. I welcome that, following recommendations from several reports to improve CAMHS, CAMHS will now be under the remit of the commission; that 16-year-olds and 17-year-olds will now be able to make decisions around their mental health treatment and that the legislation strengthens the rights of parents and guardians to information about their child’s treatment.

I would like an explicit prohibition on admitting children into adult psychiatric units and a greater onus on the HSE to provide age-appropriate facilities. I support the recommendation by Mental Health Reform that young people should be able to access mental health care in the same service up to the age of 25, as it can be very difficult for people aged 18 to move from CAMHS to GAMHS, as well as their recommendations for regulations around restrictive practices. That is a very difficult time for young people when they reach the age of 18 to have to move onto services and the services are not there for them. That is vitally important. It is clear that restrictive practices are not helpful for recovery.

I also support the World Health Organization’s opinion that electro-convulsive therapy should not be given to a young person without his or her agreement. I was disappointed to see that ECT is still in this new Bill. I urge the Government to consider the recommendations of the NGOs and of those who have lived experience when progressing this legislation. I also urge the Government to progress this legislation as soon as possible and not to make the same mistakes in next year’s budget that were made in this year’s. We need to ensure sufficient funding for mental health is prioritised and this should be reflected in the budget in two weeks.

Catherine Connolly (Galway West, Independent)
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I welcome this Bill. It is a positive Bill and I welcome the progress. Its purpose of course is to replace the Mental Health Acts, 2001 to 2022, which Acts themselves replaced the Mental Health Act 1945. I might come back to that date later, in terms of admissions for that year, and the still high admissions. Of course, this whole Bill reflects a shift on international level, forcing us every step of the way towards a human rights approach and the urgent need for legislation to reflect that. I congratulate the Minister of State. That is what this legislation is doing. It is reflecting that and the need to challenge the traditional biomedical models, the course of practices and the involuntary detentions. That has come up on just about every document I have read. I will come back again to the subcommittee in that regard because it was particularly strong on it.

We are moving from the best interest of the person, which sounds good but really is paternalistic, and replacing it with guiding principles, which I welcome. We are also doing that for children aged 16 and 17. The best interests of the child will remain, I understand, for children. We are moving to a more person-centred human rights based approach and taking account of domestic legislation changes that we have had here, namely the 2015 Act, which has not been fully implemented. The Minister of State might be able to update us on that. I apologise in advance if I am not here for her closing reply but I will read it. We have the Acts of 2015 and 2018 as well of course Ireland's obligations internationally under the UNCRPD.

It has been said many times but it is important to reiterate that given the background that has led us to this point, the Bill updates the involuntary admission and detention process for people with severe mental health difficulties, including a revised set of criteria for detention, which is very welcome; a change in the approach to consent for treatment for those who have been involuntarily detained; and an expansion, which is very welcome, of the regulatory function of the Mental Health Commission to include community mental health services, including CAMHS, where there was a gaping gap. It seeks closer alignment with the Assisted Decision-Making (Capacity) Acts of 2015 and 2022, which is extremely important; stronger safeguards for those accessing inpatient treatment and changes to the care and treatment of young people between 16 and 17, which is very welcome, allowing them, although not completely, to consent or refuse mental health treatment.

The background to all of this is something in which I have a particular interest, because in a different life in the eighties, I worked in this system. We welcomed Planning for the Future. Does the Minister of State remember that document?

Mary Butler (Waterford, Fianna Fail)
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No.

Catherine Connolly (Galway West, Independent)
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She might not remember it, but Planning for the Future was the document to change everything in 1984. That was followed by A Vision for Change covering 2006 to 2016. Again, it was brilliant. I had no problems with both documents, but I had a big problem with their implementation. Planning for the Future was to change everything from the mid-eighties onwards to stop institutionalisation, but not to cast people out into the community without care, and that is what really happened. I mentioned A Vision for Change, but nothing changed. It remained a vision, unfortunately.

A very good independent monitoring body, which sat, I think, for two sessions and, in different leaders' speeches since 2016, I highlighted repeatedly that the independent monitoring body did its work so well that it was abolished. It sat for two terms, highlighted what was progressing and what was not progressing and the response of the then Government was to abolish the independent monitoring body. Again, we do not need to hear or see anything wrong. We then got Sharing the Vision after a huge gap and after huge pressure.

I pay tribute to the Minister of State. She has done her work in this regard, but that does not stop me criticising the system and how long it took to move from A Vision for Change to Sharing the Vision. Forgive me if I am cynical and say that all we are doing here is changing language unless we make it a reality. The Minister of State, all the TDs present and I know that, on the ground, there is a big difference between the vision, whether you are sharing it or having a vision and the actual services on the ground. Eventually we got Sharing the Vision, which is going to last until 2030. In her closing reply, the Minister of State might talk about the implementation plan, which runs out this year. It was for 2022 to 2024, so where are we in that regard? Then we had an expert review group. An in-built review was provided for in the original Act and it has taken this long to get the changes again, following the statutory requirement for a five-year review. That group made 165 recommendations.

I raise the subcommittee chaired by Senator Frances Black. I pay tribute to the committee's close scrutiny of the legislation. They have put huge work into it and looked at the use of language, as did Mental Health Reform. Mental Health Reform emphasised the importance of being careful with language and how we deal with it. For example, the term "mental disorder" is included but we do not talk about "physical disorders" and so on. While we have made progress with language, although we are not very good at it as politicians in being consistent, the legislation still retains the "mental disorder" terminology.

The cross-party report recognises the key shift. It also, for the first time, puts an emphasis on challenging the medical model that has dominated in this country from time immemorial when it comes to mental illness. I congratulate the subcommittee, the chair and all those people who took part and made submissions in challenging that very strong narrative which is very difficult to challenge.

Of course, we have signed and ratified the UNCRPD, but we have not signed up to the optional protocol. Again, that is another big gap. The protocol, significantly, will establish an individual complaints mechanism, as well as individual rights, economic, social and cultural rights. The convention requires us to move away from coercion in our legislation, which deprives people of their liberty and their right to make decisions.

Earlier, we discussed freedom of expression and the very specific rights that are enumerated in the Constitution. The previous discussion was in the context of a person's good name and freedom of expression. The same article guarantees the entitlement to liberty, which has often been ignored in terms of involuntary detention. We have committed to a human rights-based system, which I welcome. The Irish Human Rights and Equality Commission says one of the key guiding principles, which is cross-referenced in all three Acts, is the inclusion of the presumption of capacity. Again, of those three Acts, the 2015 Act still has not been fully implemented. We have a serious problem with aligning legislation and filling the gaps. Again, I might be out of date on this but I understand the interaction between the 2015 Act and people who have been involuntarily detained under Part 4 of the Mental Health Act. Those two sections on involuntary detention and capacity have not been aligned either. The Minister of State might correct me if I am wrong, but the post for national director of mental health is still vacant. So we have Sharing the Vision, and Planning for the Future but then we examine what is on the ground and the resources. The inspector of mental health services said the service is "chronically underfunded". In the Mental Health Commission's annual report in 2022, the inspector of mental health services stated:

we have a chronically underfunded mental health service for many years and an inclination [an inclination] for drifting towards providing institutional care for vulnerable groups of people...

Funding allocated [allocation] to mental health has been between 5–6% of Ireland’s total health budget in recent years. [I am quoting directly from the Mental Health Commission.] This is a very low national spend on mental health services when compared internationally ... we are still a long way off from reaching the 10% ... proposed by Slaintecare.

I want to mention physical care. I thank the Mental Health Commission for its work. Dr. Susan Finnerty has repeatedly pointed out a shocking statistic: "It is hard to believe that in the 21st century, someone with a mental illness will typically die between 15 and 20 years earlier than someone without and that mentally ill people continue to suffer unnecessarily with undiagnosed or poorly managed conditions." She goes through all of that in her report. There are premature deaths 15 to 20 years earlier as a result of a failure to look at the physical side of this. She does not quite state the physical problems arising because of medication, but she says the physical problems that are there and are not being treated because the emphasis is on the mental health difficulties and medication. She is clearly highlighting that we need to look at it and it is not being looked at.

Galway got a glowing report from the Mental Health Commission. Notwithstanding the glowing report, the unit in Galway was "over capacity" and there was a shortage of staff. The numbers of occupational therapists were not appropriate to the unit's needs. There were two vacancies and it received a high-risk rating. The numbers were not appropriate and the posts remain vacant. As well as getting a glowing report, my difficulty with this was that the emphasis was put on this to the exclusion of Ballinasloe. It is history now, but bad decisions were made. There was a brand new unit. I recall the psychiatrist, Dr. O'Grady and a small team of committed people on the ground saying not to do this. They did not. A brand new unit that cost millions of euro was not used and the emphasis was put on the acute unit. Only last week, they had no space to take in a patient. Bad decisions were made. I am zoning in on this because of the breakdown of the figures. Forty-nine out of 50 are in there. Fifteen of the 49 were admitted involuntarily. There are two wards of court. When are we going to stop using that, because we have abolished it? We have a process to take away that terminology.

Mary Butler (Waterford, Fianna Fail)
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There are two more years of a lead-in.

Catherine Connolly (Galway West, Independent)
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Okay. They still have two wards of court. Five residents are in that acute unit. The word "acute" signifies something.

It is not chronic; it is acute. It has had five residents for more than six months. Interestingly, they did not tell us whether that is years or months. I believe that one or two patients, or people, have been residents in that unit for years. That ties in with the housing crisis and there being no place to discharge people. Can the Ceann Comhairle imagine that we have somebody in an acute mental health unit because there is no place for them to go? I appreciate that the Minister of State inherited this, but it is my duty to outline what is happening.

On ECT, I welcome that the committee discuss and putt a spotlight on this issue. In my time, there has always been a presumption that ECT is good without long-term evidence to prove that. Both sides of the story were given and from what the experts said, some were in favour and some were not. I welcome that a spotlight has been placed on that. I have certainly seen that ECT has been used while other therapies have not been used. I wish we would get to a point where we were not using ECT, although I acknowledge that some of the experts who came before the committee said it was effective in dealing with certain disorders, particularly persistent depression. However, when I hear things like that, I think of all the people who were committed to psychiatric hospitals over the last 100 years. Now we know what was really going on with regard to sexual abuse and rape in institutions. When people were upset they were sent to another institution. Nobody seemed to ask them what was causing their upset. Nobody seemed to say, "Where have you come from or what has happened to you?", or to create the circumstances where that person could talk. When you look at the report on mother and baby homes and the recent report on all the schools in Dublin, one particular case jumped out at me. It related to a man who had been abused and was detained in the mental hospital in Dublin. I use the word "mental" because that is what was said. He escaped from the hospital and it did not seem to occur to any psychiatrist to maybe ask a few questions about how somebody could be so depressed and upset or about the number of suicides we have had.

I welcome that a debate has started in the committee challenging the biomedical model and putting forward alternatives to it. There is, however, a big difference with what is happening on the ground. I have heard other TDs talk about people being admitted through accident and emergency units into psychiatric units, leaving and then suicide. We have a suicide watch in Galway, which makes me very uncomfortable. Tremendous work is being done but there is a suicide watch group walking the canals and rivers. Some people think we should maybe put up barriers but there are no barriers that would stop people going into water.

We need to begin to have an honest and decent conversation about the level of depression and suicide in Irish society and the failure to provide appropriate services well before people get to the stage of utter desperation. While I welcome the commitment of people who are doing that, it is our job to put the spotlight on what the figures are. What are the figures for no services? That is one of the things that jumped out of all of this - the figures for no services on the ground. We have some data on the services being provided but no data on the unmet need.

I will finish on the work being done with the organisation on the ground and the London School of Economics. I understand the LSE will publish a paper soon on the amount of money that would be saved if we had a proper service and the consequences for our economy of not having a proper service or a whole range of services in the community. Forty years ago, in 1984, that was the vision. Planning for the Future was the vision. We will always need some institutions in the truest sense of the word "asylum", where people need a rest and a break in the truest sense, although the word "asylum" has taken on a very derogatory meaning. We need some residential centres and we also need huge investment in primary care facilities on every level with regard to prevention. I welcome this as a first step.

Darren O'Rourke (Meath East, Sinn Fein)
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Colleagues, led by Deputy Mark Ward, will cover the Sinn Féin position on this issue and they will continue to engage with it. I want to focus on the issue of implementation and capacity within the system. In the first instance, I will stay local and draw attention to a response to a parliamentary question I got regarding east Meath and Ashbourne CAMHS services. It states that A Vision for Change, which we heard about in 2006 and which I remember as I worked in the health services at the time, recommended 11 clinical and two administrative staff for CAMHS teams. Currently, the team in east Meath and Ashbourne is operating at 50% capacity, or 50% of its recommended staffing level, due to the recruitment embargo over the past 12 months. Other Deputies will be familiar with the formula of words that follows because I think it is almost a red flag from the HSE. The reply states:

In light of the recently released HSE pay and numbers strategy, backfilling of vacant posts remains not permissible at this time. Louth-Meath mental health services endeavour to fill all vacant posts across all CAMHS services across Louth and Meath as soon as permission to backfill vacant posts is granted.

That, for me, is a significant concern and a red flag from the HSE. I have also had, unlike ever before, direct contact from front-line services and clinical staff saying "Stop. Something needs to be done here". There is deep concern, and I can reflect some of that from an email I received from a psychologist related to the recruitment embargo. She is working in the primary care sector. She notes that primary care psychology provides support for young people presenting with intellectual disabilities, anxiety, low mood, self-injurious behaviour, eating and sleeping concerns. It is evident, she says, that the lack of resources is having a detrimental impact on primary care services. She states:

I am concerned about the recruitment embargo. From my experience posts are not being filled. It has been noted that approximately 250 posts are currently vacant.

This psychologist wants to know who made the decision to cut the psychology posts within primary care services; how many posts in total are being cut within primary care services; in the event that previous vacant posts are made redundant, whether services be reported to be working to full capacity without the acknowledgment of these cuts; and why funding is currently being provided to outsource private assessments rather than being used to fill posts.

She goes on to say:

These decisions are resulting in extreme consequences on the mental well-being of young people, and their families, within my local area. More and more young people are presenting with mental health difficulties, resulting in school avoidance and self-harm. Without the appropriate professionals and psychological intervention their future quality of life will be impacted. They deserve better than this and for their voices to be heard! Mental support is not a luxury, it is a necessity, which has led me to have no choice but to speak up and advocate for their right to intervention and support.

I wanted to put that on the record, and the Minister of State will appreciate that it is a front-line clinical member of staff saying she has deep concerns. These are professional people committed to their patients and the people they are working with. It is very clear that they have real concerns. I flag that, as we are weeks away from the budget.

Usually, when we contact the HSE with specific questions we get generic responses. This is the opposite. We are getting very clear responses saying that the implementation of the recruitment embargo and the failure to backfill posts is going to have a severe impact on services, and it has to be addressed. If we do not have the capacity or workforce to deliver these services, reorganising the approach - no more than the implementation of A Vision for Change from 2006 - will not happen.

Pat Buckley (Cork East, Sinn Fein)
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We are back again. We have been here for a good few years. I am not here to knock this. I listened to the Minister of State's contribution last night and to our spokesperson, Deputy Ward. The fact that we are discussing this tonight on Second Stage has to be a positive. Most of us are personally affected in one way or another, so it is personal to us. I give credit where credit is due. There are always positives. We have the person-centred approach. The Mental Health Commission is involved. Some services are wrapping around. There has been mental health reform. I was in Edinburgh a while back with the Joint Committee on Autism. It was amazing to see that it has a full wraparound service where, if one has mental health difficulties and any form of autism, there is a channel and pathway to follow. It is supported by the local council. We were discussing primary care centres and how vital they are. The amazing thing about it was that the stakeholders, the kids themselves, those with difficulties or issues with mental health, meet the committee members and there is a massive joined-up system. I know we do not have that here.

Other people have talked about capacity, which has been always a worry here. The majority of people who go into the system and work in the system have been touched in some way. Like nursing, it is more of a vocation than a job. Unfortunately, we still have major problems within the mental health system. If it is not the emergency department, it is An Garda Síochána. The poor gardaí down my way are worn out from trying to help people. We are talking about assisted decision-making capacity too. I am really interested in it because it is a catch-22 scenario. I know of an adult who actually does not want to get help but the family want to help this person. At the moment, they are locked out. They can go to the Garda station to make a statement of concern about the individual's safety and so on, but the individual can just sign themselves out within an hour because they are an adult. That is a huge gap we have to look at.

Many people mentioned CAMHS. We know there are issues with CAMHS. I am not here to knock it. I am all about progress tonight. Nothing can be perfect, but progress is important. We need support and proper conditions for staff. The Minister of State, Deputy Butler, will not like me bringing it up, but we had centres that were working. Things worked; they were not broken, but somebody in the HSE decided we had to make changes That happened with the Owenacurra centre, which the Minister of State has been brilliant on, as has Mr. Gloster. I appreciate it. Much work went into it. I do not think it is perfect, but it is going back in the right direction.

A radio station contacted me the other day, asking me if I had figures of rising suicides in rural areas. People were contacting the radio stations. It is a worrying trend that I want to flag up. I do not have that information. It is bad when the radio station is ringing and asking for this kind of information.

We know we have had many reports. I have been lucky to sit on some excellent committees, including the mental health committee and the Sláintecare committee. For people outside listening in, it will be frustrating. I appeal to all sides, despite our differences, to work together. We are in here trying to work for the people beyond here. The pain, suffering and anguish of parents still seems to be high. I do not envy the Minister of State in her job. We still seem to be going at a pace that is far too slow. I am sure everybody in this Chamber gets messages, as I do every day, from family members of young kids who cannot get assessments of need and cannot access CAMHS, who are being bounced from pillar to post with excuses that they have not this but have that. We need to get access to community areas as fast as we can and fix it from there. I thank the Minister of State for her patience in listening to me.

Martin Browne (Tipperary, Sinn Fein)
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The fact that this Bill was subject to so much delay and will not be introduced in the lifetime of the Government indicates the lack of urgency the Government ascribes to mental health services. It is a shame that the level of urgency shown in closing inpatient psychiatric beds in Clonmel has not been applied to the review of the Mental Health Bill, but that appears to be the standard approach of this Government. There is a crisis in communities across the country. We have a lack of acute care and a lack of crisis care in parts of Tipperary. Instead of acute services being available when and where people need them in south Tipperary, they must travel to Kilkenny. When this decision to move acute care outside the south Tipperary area was made, where were the measures to deal with the subsequent level of demand for such services locally? We have a new step up, step down support in Haven House, but no crisis beds. Adults and children alike have to present in the unsuitable surroundings of an emergency department.

Little has changed apart from the brilliant work done by the voluntary organisations. There is outreach in Tipperary. The availability of the Jigsaw service in Clonmel has been hampered due to staffing issues. This affects any notion of early intervention for young people. The resources are not present in north Tipperary to provide outreach services outside of Thurles town. The possibility of the HSE assisting in providing a Pieta House outreach service in the west Tipperary area is something on whichI have also been workng. The HSE is dragging its heels on funding and funding remains an issue there. Will the Minister of State work with Pieta House on this, because it has been going around in circles for quite some time now?

Sinn Féin would deliver universal counselling in primary care and State-wide access to integrated mental health and wellbeing community services, including Jigsaw. We have a plan to make the system work. Locally, we also see a high level of turnover in clinical areas, to such an extent that people in receipt of treatment can find themselves in the dark about their own care, then they suddenly find out they are being assigned a new psychiatrist. I am referring to a particular scenario which I am aware of, but it is not isolated. People need the certainty of continuity of care without having to adjust to sudden changes. The same is the case for clinicians' ability to pick up where the other left off.

This brings me to youth mental health services. The vacancy rates on CAMHS teams in Tipperary is beyond unacceptable. The number of referrals declined in the two CAMHS teams in 2023 amounted to 214 out of 297 referrals. How can this be considered a service that embraces the mental health challenges experienced by young people? It is welcome to see that CAMHS will be regulated but I have two wishes here. When will it happen? We cannot wait for the Bill to go through the Oireachtas. CAMHS needs to be regulated by the Mental Health Commission immediately. The second issue relates to the level of vacancy in our CAMHS teams. It essentially reduces what there is to regulate. The shortcomings in workforce planning are leaving communities and young people without.

Sinn Féin would implement a multi-annual strategic workforce plan and significantly increase graduate and postgraduate training places to address the near-collapse of mental health services in inpatient, community and primary care settings. For adults and young people who are using drugs to self-medicate, where is the integrated staffing to provide dual-diagnosis services? Sinn Féin will legislate to obligate any Government to uphold the no wrong door policy and support health and social care services to implement such policies. I appreciate that the Bill states the gardaí will no longer do the work that HSE-authorised officers should have been doing. I want to know the details of when and where these changes will be implemented. It is something I have dealt with in the past. The current situation is not fair on gardaí or the persons involved.

I have a real concern that this Bill does not legislate to ban admitting children to adult inpatient psychiatric wards. This indicates to me that the Government considers itself to be incapable of dealing with this problem. Tipperary has been failed by this Government's approach to mental health services. Young people desperately need to see CAMHS reformed, properly regulated and staffed. Too much damage has been done through what essentially in certain circumstances has been a distant approach that was not capable of providing crisis care.

Ruairi Ó Murchú (Louth, Sinn Fein)
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As has been said by a number of my colleagues, we welcome that this legislation is going through the Houses. We have, however, particular issues. We all know there are deficiencies, whether we are talking about the community or residential settings. We all accept that there is a need for regulation of CAMHS. The big worry is the timeline for this. My colleagues have outlined our proposals and the specific issues about which we have concerns.

It is worth mentioning the Garda no longer being gatekeepers of mental health. We all know the issues that created for gardaí and the imperfect circumstances. We need to ensure there is a sufficient number of authorised officers capable of making the necessary decisions. We have all dealt with bad situations involving people who are a danger to themselves or others. Occasionally, it takes a number of attempts and a huge amount of resources from the Garda, doctors and others to get some sort of mental health intervention. There is a need to look at this entire area. I understand we are moving away from the horrible situation in years gone by when there was an insufficient human rights ethos but it is about getting that balance right. It is not always straightforward.

We are all aware of the work done by supported and unsupported services. In Dundalk, there is the new Pieta House service in the Redeemer Family Resource Centre. I spoke to its representatives in the past week about funding. The situation is very sad. The service needs a roadmap. It provides a huge amount of support and services for those going through mental health anguish. I will raise that issue with the Minister of State. Deputy Ward and I visited Dundalk Counselling Centre. A spectacular amount of work has been done. I have funnelled certain issues through. It is all about sustainable funding and being able to deliver the service.

I have inquired about an issue with the HSE and have not received an answer. I hope the Minister of State can bridge that gap. Concerning the Drogheda Department of Psychiatry in Crosslanes, planning permission was submitted over six months ago for a ten-bed extension at the Drogheda site but there is no news about commencement. Counties Louth and Meath have poor bed provision compared with the rest of the State. I think the ratio is 12.9 beds per 100,000 whereas the State average is greater, although I accept that needs to be increased. I was told at one stage before the moratorium was lifted that there were around 40 nursing and mental health service vacancies. Following the lifting of the moratorium, this number became 13. I was told that positions left by nurses acting up no longer exist. I did not just get this information in the bar. Will the Minister of State follow up on the issue? In relation to Crosslanes, the Mental Health Commission stated that at times there was insufficient staffing. It is an issue. While we want the extension, we need to make sure there is a sufficient number of staff to provide a safe service in Crosslanes and the entirety of Louth and Meath. I think there were 49 occasions - day shifts and three night shifts - since January 2023 when the approved centre's nursing staff was below the required staff ratio. This presents a worry. I was told that at one stage there were 40 positions that were not filled. That was for nurses. If we were to extend that to other disciplines, there would be a greater level of unfilled posts. Will the Minister of State provide detail on that issue?

An issue I previously brought up with the Minister of State is that there is no 24-hour psychiatry service at Our Lady of Lourdes Hospital, Drogheda. At night, this sometimes leads to chaotic circumstances in which people go to the Drogheda department of psychiatry in Crosslanes when the assessment should happen away from there. It goes from a doctor, to our Lady of Lourdes Hospital, to the accident and emergency department. We do not have the conversations that are needed or the service that needs to be provided across the board. As we face into budget season, it would be good if could deal with some of these issues.

Violet-Anne Wynne (Clare, Independent)
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I pay tribute to Councillor PJ Kelly. Everyone would say he had a mighty way with words. From every political determination, that is something they could at least agree on. I will never forget his words that you may put a gate at Lissycasey because there is nothing else past that in terms of funding and resources from Government. For that, he will always be remembered. I express my deepest sympathies to his family, friends and colleagues.

One in two people in Ireland will experience a mental health difficulty directly or indirectly. We all know this and many of us mentioned it in our contributions. This is a 164-page, 202-section Bill. After a thorough reading, I will reference some parts which were a missed opportunity. I am aware that the Government has indicated there are a number of amendments it hopes to bring forward and that it was not possible to include all recommendations by the committee on previous Stages. In respect of the recent south Kerry CAMHS scandal, for example, it is tempting to be glad that the office of the chief inspector position will inspect each centre at least once every five years but the lack of an independent system for service users or their parents to make complaints makes it hard to see this as a complete victory for patients. I find that omission glaring, if I may be so bold as to say that. I hope it will be addressed, as one might think this Government is almost afraid to allow patients the respect and dignity they deserve by ensuring there is a mechanism to complain with ease and have their voices heard without fear of repercussion from the very service they so desperately need. This issue was brought to the forefront thanks to the fantastic work of the Families for Reform of CAMHS, which indicated that an awful lot of its members - I believe 35% - felt they suffered in some way once a complaint was submitted. When that was brought to light, it should have set the foundation for all Departments to consider that there must be a pathway for recourse and communication and for patients to seek a resolution to their concerns. That must be best practice, at the least, when going forward.

Although this Bill covers many issues to do with children in the mental health system, there is no mention of the problem of children being admitted to adult inpatient beds. Children spent 217 days in adult psychiatric institutions due to a lack of children's beds in 2022. In that year, there were 72 child inpatient beds. This was cut to 51 and by March this year, it was down to 30 due to staff shortages. For a Bill which provides for the involuntary admission of children to and discharge from registered acute mental health centres, this feels like another glaring omission. However, it is not like passing the legislation would be a guarantee that the Government would be able to follow it. I say this with the greatest of respect and the knowledge that there may be a different government coming in. It is well known by service users that an assessment of need, for example, can take up to two years to procure despite the requirement under the Disability Act that it take a maximum of six months. With this in mind, the Government appears over-optimistic in preventing An Garda Síochána from administering involuntary admissions to psychiatric care. We know the Garda is overworked. A Garda station is not an appropriate place to receive anything but the most urgent healthcare. It undeniably reflects poorly on our mental health service that 30% of involuntary admissions last year came through An Garda Síochána. However, I do not see any framework in this Bill to put the pressure which we know is placed on An Garda Síochána anywhere else.

That must be addressed and I hope it will be by the incoming amendments.

As regards the long-standing issue of gardaí making 30% of the applications for involuntary admissions, the Bill removes Garda powers to involuntarily admit someone for mental health treatment but still gives the Garda the ability to involuntarily detain people in custody for up to 18 hours pending assessment. The Bill proposes to solve that by giving greater powers to authorising officers but I have to make the point that the HSE is already understaffed. I received this information through a recent parliamentary question response. There are 1,377 whole-time equivalent nursing positions vacant in UHL and 133 permanent vacancies as of August this year.

Mental Health Reform says that the authorising officers must be available 24-7 in every county and I fully agree with that. In the run-up to the 2020 general election, I campaigned on the need for that kind of consistent and accessible mental health service and support. However this appears unlikely given the current under-resourcing of the HSE. We know there is a ceiling in place. In 2015, when the expert review group was formed only 100 officers were in place nationally and in 2020 the numbers had fallen by 20%. Nevertheless, I also note medical practitioners must assess patients within 24 hours of a request for involuntary admission being received and assessing officers must file the application paperwork within seven days. While the Mental Health Commission welcomes the explicit timeframes, the assessment of needs framework also comes with an explicit timeframe and this Government has been ignoring that since the day it passed. That needs to be said.

An aspect of the Bill I find particularly worrying are the sections authorising restraint and seclusion, including on children. The Mental Health Commission has been attempting to reduce restrictive practices in this country for more than a decade. The World Health Organization has been offering training for service providers working in the mental health space without relying on seclusion or restraint for the last five years, yet this Bill allows for the provision of restraint, seclusion and electroconvulsive therapies for children either under the age of 16 but admitted with parental consent, or over the age of 16 and admitted with or without parental consent. Guardians have to be notified but the phrase "as soon as possible" is used. If the World Health Organization considers these practices to be contrary to our obligations under the UN Charter on the Rights of Persons with Disabilities, why on earth are we codifying their legality?

This feels like a good time to point out, yet again, that the optional protocol to the UNCRPD has not yet been ratified although a commitment has been given to do so by the end of the year. This was given in February but I have still not heard any indication that this timeline will be adhered to. We live in hope, however, and we will wait and see over the coming weeks.

We would establish an individual complaints mechanism and make these binding obligations more accessible for people on the ground. This Bill does not have that independent mechanism and we still have not ratified the optional protocol. I have made the point time and again in this Chamber and since I first attended the disability matters committee in 2020 that the UN special rapporteur had pointed out that there was really no justification for the ratification of the optional protocol not being done at the same time and on the same day as the ratification of the UNCRPD, other than leaving those in need without access to an independent mechanism to be able to make complaints against injustices they feel they are experiencing, which is hugely important. That sends a clear message that there is no fear. People have the right to make complaints and there is nothing wrong with making complaints. That is something we could do with an awful lot more of in our society - that it is okay to speak up and speak out.

In general, the Bill is positive and I have heard the Mental Health Commission welcomed it, specifically the inclusion of the measure regulating CAMHS for the first time. That is something I have called for for some years and it is positive to see. While there is a chief inspector, the lack of an independent system is still a gap in the Bill. While the Mental Health Commission gave its approval of the Bill on Monday, it is my understanding that it did not have full access to the text. Perhaps the Minister of State can clarify that. Maybe full access has been given since, but that is an important point to note.

There are strong links with the Assisted Decision-Making (Capacity) Act's preference for independent decision-making assistance and the move away from paternalistic, best-interest models. The Assisted Decision-Making (Capacity) Act was passed in 2015 but only came into effect in 2022. It was, therefore, a seven-year process. The Mental Health Bill, like the Act, has been critiqued for not going far enough but there has been an indication that amendments will come forward. I hope they will address these missed opportunities.

I am aware that the heads of the Bill include concerning language. I refer to the reference to the word "disorder". That must surely be a mistake and it has to be amended immediately. I do now know how that was missed. Along with Deputies Connolly and Pringle and a few others, I attended Mental Health Reform's event with Jigsaw which focused on language and discussing mental health in a way that can reduce stigma, is in line with European best practice and also, very importantly, normalises access to services. In this House, we hear of very extreme cases. It was pointed out at the briefing that we should be more mindful that there are a large number of cases in the middle, that people have good experiences when they are accessing services and that it is okay to reach out as well. With all of that in mind, it might have been beneficial to have had someone from the Minister's office in attendance at the briefing because it is good to hear from those who know best. Síofra and Jack, who spoke on behalf of Jigsaw, outlined their experience of hearing triggering words and derogatory language being used when people are speaking about those who have mental health difficulties. As I stated, one in two people can be affected either directly or indirectly so we need to grapple with the kind of language we in this House all use when we discuss mental health. The Ombudsman for Children has also flagged this serious matter. I hope the commitment to bring forward more Government amendments is adhered to and that language is removed.

The timeframe of ten years for the review of the legislation is far too long because we know the period always extends for much longer than planned, so the timeline will probably be longer than ten years. I ask that the timeline be reduced significantly to ensure it is realistic and beneficial.

I also refer to the significant delays with the de-escalation service in Limerick. The service was supposed to open recently but is still delayed. It cannot be delayed any further. I cannot emphasise that point enough because there are so many people in need.

It is important to mention the mental health budget in recent years. The last time a double-digit percentage of the health budget went into mental health was in 1984. I know we have not been able to get that figure above 5% to possibly 6% in recent years.

I hope that the Department gets the budget it needs on 1 October, which will send a specific message to public bodies and local authorities, for example, so they can understand the importance of prioritising mental health and understand that they should not dismiss somebody when they say they are struggling and need help and support. I will also send a message to those who need to hear it that their mental health is a priority today. They have suffered many delays, but it will no longer be on the promise of tomorrow.

Mary Butler (Waterford, Fianna Fail)
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I thank the Deputies for their contributions yesterday and today. The statements on the Bill have mostly been productive, positive and have all been in the spirit of seeking to improve our mental health services. I would also like to acknowledge the fact that Deputy Mark Ward sat through every minute of this debate, both last night and today.

Mark Ward (Dublin Mid West, Sinn Fein)
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Thank you.

Mary Butler (Waterford, Fianna Fail)
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I think that should be acknowledged and I thank him for that. I also want to acknowledge the new interim CEO of Mental Health Reform, who was also present last night and is here today. Deputy Wynne need not have any worries because I engage constantly with Jigsaw and Mental Health Reform, as do my officials. She does not need to have any concerns there. That is ongoing in the Department on a monthly basis.

Yesterday evening, Deputies spoke about some of the complexities of the Bill, such as the criteria for involuntary admission, the powers of An Garda Síochána, and the importance of language and terminology in this legislation. Many of these issues were subject to lengthy consultation and extensive legal advice during the development of the Bill, and I recognise that it will be important for the rationale that underpins these issues to be discussed in more detail as we move through the legislative process. There were several reasons the term “mental disorder” felt most appropriate, but we can discuss this on Committee Stage. I know it was discussed in detail at pre-legislative scrutiny, and there was not another wording people felt was appropriate, but we can discuss all that going forward. I want to acknowledge the work of Senator Frances Black and the Oireachtas committee on mental health, of which Deputy Ward is also a member, for the amount of work done on pre-legislative scrutiny.

As we all know, this work cannot be done overnight, and the Bill that is before us today is the result of years of hard work. The matters that have been raised by Deputies during this debate will continue to be examined in great detail on Committee Stage, and I look forward to engaging in further discussions. In case anybody did not hear this yesterday, we currently have 211 authorised officers in place, and we will continue to build on that number, because there is a genuine concern that when the powers are removed from An Garda Síochána, the availability of all authorised officers in all areas is important.

Chapter 6 of the Bill includes 38 sections relating to the regulation of mental health services, including all community mental health services. Establishing the legal basis to regulate services for the first time requires the solid legal foundation that Part 6 provides. As I have stated in the past, I do not believe it could be achieved by an amendment to the existing Act. The new Bill provides the opportunity to embed the regulation of community services and put all mental health services on a firm legal footing.

Turning briefly to COSS, I am glad to see Deputies welcome the enhanced role for the authorised officers in the involuntary admission process in the Bill. I agree that the HSE must expand the authorised officer system and ensure they are available across the country and outside regular working hours. Officials in my Department will proactively engage with the HSE on the authorised officer system and all other costs associated with the Bill. The broadening of the regulation of community services will also require capital investment from the State in order to ensure that mental health services are delivered in appropriate settings that best meet the needs of service users. Officials in my Department will continue to work across all relevant Departments to ensure that the commencement of the Bill is well planned for. This will include ensuring that the available resources are put in place for the phased and prioritised implementation of this legislation.

The Mental Health Bill 2024 further exemplifies this Government's commitment to improving mental health services. The clear commitment to enhancing services is shown by significant mental health funding increases in recent years. This commitment was reflected again in budget 2024, which saw record spending on mental health rise to more than €1.3 billion. This is the fourth consecutive year in which an increase has been provided to support mental health services.

There was some discussion during the debate on Sharing the Vision, our new mental health policy which puts the service user front and centre. I will give an update on the national implementation and monitoring committee. One of the first jobs I did was putting that in place in 2020. The national implementation and monitoring committee, NIMIC, is tasked with driving and overseeing policy implementation, and its work is progressing well. As of the most recent report, which was dated May 2024, 80 of the 100 recommendations on Sharing the Vision are marked as on track. Five recommendations have been marked as completed. The delivery of the policy is currently guided by Sharing the Vision 2022 to 2024 and work has commenced on the development of the second implementation plan to cover 2025 to 2027, with vital stakeholder engagement under way. Yesterday, for example, under the new chair, Catherine Brogan, a second regional meeting was held. This one was actually held in Waterford. The last one was held during the summer in Galway. Some 75 delegates were present, all discussing Sharing the Vision, the implementation plan, and the new implementation plan for 2025 to 2027. That work is therefore under way, regardless of who is in this particular role. It is great to see NIMIC, which is doing phenomenal work.

The Mental Health Bill 2024 is one strand of a wider programme of reforms in the mental health sector. Enhanced investment continues to underpin the implementation of our national mental health policy, Sharing the Vision, and our national suicide reduction policy, Connecting for Life. Through these policies, the Government is delivering tangible improvement across mental health services, for example, through the development of out of hours supports, CAMHS services and the national clinical programme and models of care.

Last week, I travelled to Castlerea in Roscommon for the first ever Discovery West service, a day hospital supporting young people through their mental health journey. I have to say, the collaboration between the schools, libraries, CAMHS teams, CAMHS Connect and the young people was something to behold. It was fantastic to see it.

Deputies will be aware that mental health services for children and young people are a key concern throughout the country. It is very important that children's rights are recognised and upheld. To this end, I very much welcome the changes that the Mental Health Bill proposes in this regard. Improving access to CAMHS remains a key focus for me, and I want to assure the House that as this Bill progresses and as it is commenced, the Government will retain that much-needed focus on CAMHS service improvement and will continue to work to reduce waiting times and improve access. Additional funding and service improvements have had a positive impact on CAMHS. As an example, in July 2024, the CAMHS national waiting list had reduced by 13% compared to the same period last year. In addition, the July 2024 waiting list saw 27% fewer children waiting more than 12 months for an appointment than in July 2023. I acknowledge that there are challenges in our youth mental health services and there is much more work to be done. However, I wish to assure the Deputies that I remain fully committed to improving at every level, be it through service improvement, service redesign, or legislative reform.

In conclusion, I am proud to stand before the House today to introduce this Mental Health Bill. I believe this is a progressive Bill that is person-centred and human rights-based. It respects the autonomy of people with mental health difficulties to make decisions about their care and treatment. It sets out the necessary legal underpinning for significant expansion of regulation to all community mental health services. I look forward to continuing the debate on the provisions of this Bill on Committee Stage, and I look forward to debating the merits of amendments proposed by both Government and Opposition. I would like to reiterate that all amendments tabled will be given due consideration. I am also conscious of where we are within the electoral cycle, but I do believe that if we all work together, we could move this very quickly. Obviously, if it passes Second Stage today, the next Stage will be at the Oireachtas committee. I do believe there is a willingness across everyone who spoke, both last night and today, to try to get this done as quickly as possible. I think too much work has been done for that not to happen.

We now have the opportunity to introduce a Bill that is forward-thinking and may be in place for decades to come. As Deputies will appreciate, this legislation will mean a great deal to many.

I look forward to working with the Members of both Houses on progressing this as swiftly as possible. I ask the Deputies to support the Bill.