Address by Mr. Tim O´Malley, T.D. Minister of State at the Department of Health and Children on Private Members´ Motion on Disability

A Chathaoirligh,

I am pleased to have an opportunity tonight to speak on issues relating to the provision of services to people with mental illness and to outline the measures being taken by the Government in this area. I propose to share my time with Micheál Martin, Minister for Health and Children.

I have listened carefully to the contributions to this debate so far and I would like to say at the outset that I fully recognise the need to further improve standards in our mental health services. I would like to assure the House that there is an equal amount of compassion on this side of the House regarding the issue of mental health services. No one person has a monopoly of compassion in this area.

Amnesty International´s report, “Mental Illness – The Neglected Quarter” which was published earlier this year highlighted areas of genuine concern in relation to mental health services. These are concerns which this Government shares and which it fully intends to address.

I think it would be helpful if I began by referring to the document which has been the cornerstone of mental health policy for successive Governments for almost 20 years. “The Psychiatric Services – Planning for the Future” developed the concept of a comprehensive psychiatric service located in the community close to where people live and work. It was envisaged that this would replace the centralised and largely institutional services which were planned at a time when modern treatment methods were not available.

Unfortunately, the rate of progress over the last 20 years in closing down the old hospitals and building up the community services has not been as fast as had been hoped. It has to be acknowledged that, over the years, the mental health services have frequently lost out to other services, which have been given priority in the allocation of development funding. If we are to sustain and develop the concept of a comprehensive psychiatric service located in the community, adequate funding and support must be provided. I fully recognise that much needs to be done in this regard.

Substantial capital funding under the National Development Plan has been allocated to the development of mental health facilities. Approximately €190m is being provided over the lifetime of the plan which will enable the further provision of acute psychiatric units attached to general hospitals and the provision of additional community-based facilities.

The Inspector of Mental Hospitals plays a crucial role in providing an independent and detailed analysis of the mental health services. On the publication of his report for 2001 in September of last year, I was the first to acknowledge that more needs to be done to further improve the quality of our services. Notwithstanding the shortcomings which have been identified, there have been many improvements in the services, which have been outlined in successive annual reports of the Inspector of Mental Hospitals. These relate particularly to the increase in the number of acute psychiatric units associated with general hospitals. In 1983, prior to the publication of “Planning for the Future”, there were ten such units in place; this has now increased to nineteen with a number of others at various stages of development. The number of community residences in 1983 was 111 with less than 1,000 places. In 2001 this had increased to 404 with more than 3,000 places. In the same period the number of in-patients in psychiatric hospitals and units has reduced from approximately 13,000 to just over 4,000. The decline in numbers of new long-stay patients does not necessarily reflect a decline in the incidence and prevalence of psychiatric illness as a whole. However, it is clear that hospitalised prevalence of serious psychiatric illness has declined greatly in recent years. Patients are increasingly being cared for in settings other than in-patient care with less disruption to their daily lives.

It is my intention to continue to accelerate the growth in more appropriate care facilities for persons with a mental illness with the further development of community-based facilities throughout the country. Substantial additional revenue funding has been provided since 1999 for the enhancement and development of community-based mental health services. This is being used, in the main, to provide additional medical and health professional staff for expanding services. Again, this commitment of funding has led to considerable progress being made in increasing the number of new mental health centres, day hospitals and other day facilities.

Since coming to office, I have taken the opportunity of visiting a number of psychiatric hospitals and have seen at first hand the commitment of professional and nursing staff to the provision of a high quality service. From the outset, I accepted that further investment needed to be made in upgrading or replacing some of the physical facilities and that a greater capital investment was required to provide a community-based infrastructure.

The World Health Organisation´s 2001 Report, “Mental Health: New Understanding, New Hope”, was aimed at raising public and professional awareness worldwide of the burden of mental illness and its costs in human, social and economic terms. It is a comprehensive review of all aspects of mental health, from prevalence and treatment to service provision and planning. It concludes with a set of ten broad recommendations for action.

Steady progress has been made in this country over recent years in many of the areas covered by the World Health Organisation’s recommendations, for example, in the shift from institutional to community-based care and in the reform of mental health legislation.

The Amnesty Report also recommended that a comprehensive review of the mental health services be undertaken. I welcomed that recommendation at the time, because the National Health Strategy, “Quality and Fairness – A Health System for You”, published in 2001, had recognised the need to update mental health policy to take account of recent legislative reform, developments in the care and treatment of mental illness and current best practice. The Strategy gave a commitment that a national policy framework for the further modernisation of the mental health services, updating the 1984 document, would be prepared. An expert group will be established shortly to undertake this work. Work on a draft scoping document and terms of reference for the group is almost finalised within the Department and I am pleased to inform the House that the recommendations of the World Health Organisation will be among the matters to be considered in the formulation of this new framework.

The present Inspector of Mental Hospitals plays a crucial role in providing independent and detailed analysis of our mental health services and I would like to take this opportunity to pay tribute to Dr. Dermot Walsh, Inspector of Mental Hospitals for his trojan work in this area for many years. The Inspectorate has provided both expertise and assistance in identifying problems and outlining the need for improvements. Under the provisions of the Mental Health Act, 2001 the existing office of the Inspector of Mental Hospitals will be replaced with the Office of the Inspector of Mental Health Services, thus giving the new Inspector a much broader statutory remit than that of the current Inspector. I understand that the Mental Health Commission is currently recruiting the new Inspector and it is hoped that he or she will be in a position to commence inspections in 2004.

In addition to the annual inspections of in-patient facilities which are carried out at present, the new Inspector will be required to carry out an annual review of all mental health services including community residences and day centres as well as acute in-patient facilities. The Inspector´s review of the services, including reports of inspections carried out, will be published along with the Mental Health Commission´s annual report and will be laid before the Oireachtas.

Another important responsibility of the Inspector will be in relation to the regulation of standards in the mental health services. The new Mental Health Commission will maintain a Register of Approved Centres, in which each hospital or in-patient facility providing psychiatric care and treatment must be registered. Regulations will be made specifying the standards to be maintained in all approved centres, including requirements in relation to food and accommodation, care and welfare of patients, suitability of staff and the keeping of records. The execution and enforcement of these regulations will be the responsibility of the Mental Health Commission, through the work of the Inspector of Mental Health Services.


It is my firm belief that this will lay the foundations for achieving a sustained improvement in the quality of care provided in our mental health services. Both the Mental Health Commission and the new Inspector of Mental Health Services will play a pivotal role in this regard. The current Inspector of Mental Hospitals has, however, already begun this process. A document entitled Guidelines on Good Clinical Practice and Quality Assurance in Mental Health Services was prepared by the current Inspector and published by the Department in 1998. The guidelines are an educational endeavour to increase awareness of the main quality issues in service delivery and their monitoring, refinement and improvement. They have been circulated to mental health professionals and service providers around the country. I would anticipate that similar guidelines and other measures would be developed by the new Commission to assist service providers in their pursuit of excellence in care delivery.

In the period 1999 – 2002, an additional €70.7m was invested in the mental health services. In the current year, additional revenue funding of €7.6m is being provided for on-going developments in mental health services, to develop and expand community mental health services, to increase child and adolescent services, to expand the later-life psychiatry services, to provide liaison psychiatry services in general hospitals and to enhance the support provided to voluntary agencies.

Priority is being given to the development of mental health services for Psychiatry of Later Life and Child and Adolescent Psychiatric services. Additional resources have been made available by my Department to enable on-going developments in these services. I recognise that the increasing number of people living to advanced old age will require the development of specialist mental health services which will meet the specific needs of older people. Psychiatry of Later Life is therefore a key area for development and over €7m additional revenue funding has been committed since 1999 to enable a start to be made on the establishment of specialist services in health boards where no such service had heretofore existed. I am committed to the continued development of this specialist service in the coming years.

In relation to mental health services for children and adolescents, I acknowledge that services for this group still require substantial development. However, we have already come a long way. In 1997, there were few Child and Adolescent Psychiatry services available outside the major cities. Now each health board has a minimum of two consultant-led, multi-disciplinary teams.

A Working Group was established by my Department in June 2000 to review child and adolescent psychiatry provision and to finalise a plan for the further development of this service. The Group published their First Report in March 2001. It emphasised that the treatment of ADHD/HKD is an integral component of the provision of a comprehensive child and adolescent psychiatric service. It recommended the enhancement and expansion of the overall child and adolescent psychiatric service throughout the country as the most effective means of providing the required services for this group. It also recommended that priority should be given, in the first instance, to the recruitment of the required expertise for the completion of existing consultant-led multi-disciplinary teams. The Report also called for closer liaison and interaction with the education system and other areas of the community health services.

In its first Report, the Working Group also examined the issue of in-patient psychiatric services. It recommended that a total of seven child and adolescent inpatient psychiatric units for children ranging from 6-16 years should be developed throughout the country. It envisaged that the focus of these centres would be the assessment and treatment of psychiatric, emotional or family disorders including major adjustment disorders, anxiety disorders, mood disorders, eating disorders and schizophrenia.

At present, four of these child and adolescent psychiatric in-patient units are at the planning stage and project teams have been appointed to oversee their development. These units will be built in Dublin, Cork, Galway and Limerick.

In addition to the above, the Working Group has also considered the provision of psychiatric services for 16-18 year olds and its report on this important issue was formally presented to me earlier today by the Group´s Chairperson, Dr Paul McCarthy. I welcome the findings of this latest report. It recommends that priority should be given to the recruitment in each health board area of a Consultant Child & Adolescent Psychiatrist with a special interest in the psychiatric disorders of later adolescence. This consultant should have the support of a full Multi-Disciplinary Team. The Report also emphasises the need for closer co-operation and liaison between the child and adolescent psychiatric services and the generic adult mental health services. As I said, I welcome this latest Report which will serve now as a basis for policy-making and planning in this area. I would like to place on record my appreciation of Dr McCarthy and the other members of the Working Group for their work.

The Working Group on Child and Adolescent Psychiatry is now examining the needs of persons suffering from eating disorders and how appropriate services can be developed in the short, medium and long term. The working group has invited submissions from interested parties on how the needs of persons suffering from an eating disorder can best be met, and will be preparing its report on the matter over the coming months.

My Department has, over the past few years, given special attention to the resourcing of suicide prevention initiatives. As we are all aware, suicide has become a serious social problem that is not confined to Ireland but is a growing global problem. Suicide is now the most common cause of death among 15 to 24 years olds in Ireland exceeding deaths due to cancer or road traffic accidents. Apart from the increase in the overall rate of suicide, a disturbing feature is the significant rise in the male suicide rate.

The most recently published figure from the Central Statistics Office indicates that there were 451 deaths from suicide in 2002. The figures highlight the need to intensify our efforts and to put extra resources in place for suicide research and suicide prevention programmes.

Since the publication of the Report of the National Task Force on Suicide in 1998 there has been a positive and committed response among both the statutory and voluntary sectors towards finding ways of tackling this tragic problem. A Suicide Research Group has been established by the Chief Executive Officers of the health boards. Resource officers have been appointed in all health boards with specific responsibility for implementing the Task Force’s recommendations.

The Task Force recommended that steps be taken to make the mental health services more accessible to the public, particularly to young people. Concern was also expressed at the risk of suicide in older people. Additional funding has been made available to further develop consultant led child and adolescent psychiatry and old age psychiatry services to assist in the early identification of suicidal behaviour and provide the necessary support and treatment to individuals at risk. Many of the Task Force’s recommendations require continuous development, particularly in the area of training and in the development of services relating to suicide and suicide prevention.

Additional revenue funding of €0.655m has been provided this year for suicide prevention programmes. Therefore, since the publication of the Report of the National Task Force on Suicide in 1998, a cumulative total of more than €13m has been provided towards suicide prevention programmes and for research. This includes funding to support the work of the National Suicide Review Group, The Irish Association of Suicidology and the National Suicide Research Foundation for its work in the Development of a National Parasuicide Register.

This Government is fully committed to ensuring that further investment takes place in this area, building on the achievements to date.

The development of advocacy services in Ireland is a very recent occurrence, but it is another example of the significant improvements which are taking place in the provision of mental health services. An advocate can be someone who can represent and defend the views, needs, wishes, worries and rights of individuals who do not feel able to cope themselves. Advocacy can also help service users to participate in and make decisions about their care and treatment. It can be a mechanism for changing attitudes of the public and media towards mental illness and those experiencing it.

The importance of advocacy is far reaching. Not only does it allow the patient to express his or her concerns but it may also foster recovery by assisting patients to take control of their lives and their future. The power of self-help is a critical factor in any healing process. A sense of being able to share and discuss one’s fears and emotions within an understanding environment is invaluable and of tremendous solace at a time of crisis. That is the core of what advocacy is about.

Patient advocacy in the mental health services is still in its infancy in this country. However, there are some groups that have been providing informal advocacy services to patients and families of the mentally ill for some time, and in recent years, a national patient’s advocacy network has been established, with funding from the Department of Health and Children and various health boards.

This Government has made clear its support of the development of advocacy services in Ireland by assisting initiatives to provide independent advocacy services. I made available €251,000 in 2002 and an additional €100,000 in 2003 for the development of mental health advocacy services nationally.

Substantial progress has been made in recent years in Ireland in ensuring that those in need of mental health services receive care and treatment in the most appropriate setting. However, I accept that much remains to be done. This Government is committed to the provision of quality care in the area of mental health, to upholding the civil and human rights of those who suffer from mental illness and to encouraging measures aimed at combating the stigma that is often associated with such illness. Advances in the management and treatment of mental illness now allow many sufferers to live within their own communities, to carry on with their lives and to continue to contribute to our society in a positive and fruitful way.

During my term of office as Minister of State with special responsibility for mental health, I will be endeavouring to secure additional funding for the mental health sector in the coming years. I will also be overseeing the development of the new National Policy Framework for mental health, to which I referred earlier. This will devise a sound policy base for the further enhancement and modernisation of our mental health services over the next decade.

In conclusion, I believe that the initiatives which I have outlined will reassure this House that mental health services are not being neglected by this Government and that the service shortcomings identified by recent Reports are being addressed.

As I mentioned earlier, I now propose to share the remainder of my time with Minister Martin.