We have received apologies from Senator Nicole Ryan. Senator Kennelly will substitute for Senator Manus Boyle. The minutes of the meetings of 24 and 25 February have been circulated. Are they agreed? Agreed.

I remind members of the constitutional requirement that they must by physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside Parliament will be asked to leave the meeting. In this regard, I ask members participating on MS Teams that, prior to making a contribution to the meeting, they confirm they are on the grounds of the Leinster House complex.

Today, the committee resumes its consideration of access to child and adolescent mental health services, CAMHS. This is the second session on CAMHS, following last month's meeting with Families for Reform of CAMHS, Jigsaw and Spunout. At that meeting, it was clear that families are still having to fight for services and vulnerable children continue to fall between the cracks, despite parents' best efforts. Although we continue to receive assurances that things are changing, I did not get that sense from the parents at the coalface.

Since the last session, the look-back report into north Kerry CAMHS has also been published. That report, the Maskey report into CAMHS in south Kerry and the Mental Health Commission 2023 review all identified significant failings in CAMHS, with serious, even devastating, consequences for children and families. We need to know that the recommendations of all these reports are being implemented, that the postcode lottery in children's mental health services will finally be addressed and, crucially, that accountability will be more than a buzzword when things go wrong.

To address these matters, I welcome, from the Health Service Executive, Dr. Amanda Burke, the national clinical lead, child and youth mental health office; Mr. Donan Kelly, assistant national director, national mental health office; Dr. Andy Phillips, regional executive office, HSE South West; Ms Julie O'Neill, integrated healthcare area manager in Kerry, HSE South West; and from the Department of Health, Ms Siobhán McArdle, assistant secretary; and Ms Siobhán Hargis, principal officer.

Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that may be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against a person or an entity outside the Houses or an official either by name or in such a way as to make him, her or it identifiable.

To commence today's proceedings, I invite the witnesses to make their opening remarks.

I thank the Chairperson and members for the invitation to meet with the Joint Committee on Health to discuss access to child and adolescent mental health services. I am joined by my colleagues, Dr. Andy Phillips, regional executive officer, HSE South West, Ms Julie O’Neill, integrated healthcare area manager, Kerry, HSE South West, and Mr. Donan Kelly, assistant national director for child and youth mental health.

Our mental health is influenced by many different factors. While the continued enhancement of specialist mental health services is crucial, the mental health of our young people depends on a broad public health approach that builds on collaboration across the health services, the education sector, statutory and voluntary bodies, and within our communities.

The age of onset of mental health difficulties typically falls around the mid to late teenage years and early 20s, and adverse early childhood experiences can be a significant predictor of serious mental health difficulties in later life. In the development of youth mental health services, it is, therefore, critical that we prioritise the promotion of mental health, intervene early when problems develop and ensure clear pathways to community-based mental health services for those who need extra supports.

CAMHS is a specialist mental health service for a small proportion of children and young people who have a moderate to severe mental health difficulty. For these children and young people, it is particularly important to have access to integrated and person-centred supports provided by a multidisciplinary team of skilled professionals.

Last year, our CAMHS teams received over 29,000 referrals, an increase of more than 14% on the previous year. In excess of 230,000 appointments - 8% more than the previous year - were provided for children and young people in need of support.

Some 69% were seen within 12 weeks. However, at the end of 2025, there were 4,462 children and young people waiting to be seen, of whom 602 had waited 12 months or longer. As a result of targeted initiatives, we have seen a small but important decrease in the number of young people waiting 12 months or longer, but CAMHS waiting lists remain challenged by a growth in demand for services, coupled with the impact of ongoing staff retention and recruitment difficulties.

It is critical that we provide timely access for those who need the support of CAMHS. I fully understand how difficult it can be for families when they have to wait longer than is reasonable for that support. It can have a tremendous impact on a family when a child or a young person is having mental health difficulties. On behalf of the HSE, I wish to apologise to those who have experienced shortcomings in accessing our services.

Performance is variable across health regions. While some areas have relatively short waiting lists, waiting times are longer in other regions. Factors such as staff vacancies and recruitment challenges can impact on wait times, as well as the extent to which early and lower-level interventions are available in a particular area. As part of the HSE’s waiting list action plan, a recurring funding stream of €3 million has been allocated across the six health regions specifically to address the longest waiters on the CAMHS waiting lists. Between 2022 and September last year, an additional 4,712 cases were seen as a result of this initiative. Every effort is made to prioritise urgent cases so that referrals of young people with high-risk presentations are addressed as soon as possible. This is often within 24 to 48 hours, and last year, 96.3% of all urgent cases were responded to within three working days. The severity of presenting symptoms and risks is always taken into account in assessing waiting times.

There has been a significant investment in youth mental health services and CAMHS over a number of years to meet this increased demand and to develop comprehensive services for children and young people with mental health difficulties. In the last two years alone, an additional €32 million has been directed to enhance CAMHS services, bringing the total funding in 2025 to approximately €181 million, with a further €7 million allocated for service improvements this year. Since 2023, an additional 19 whole-time equivalent clinical posts have been added to our workforce. There are currently 75 multidisciplinary core CAMHS teams in place, which provide critical assessment and treatment services. Alongside these targeted enhancements of capacity in our CAMHS teams, the HSE has invested in specialist teams, including for young people who are experiencing eating disorders or mental health and intellectual disabilities. It has also invested in digital mental health and in services such as Jigsaw for children and young people with mild to moderate mental health difficulties who do not need to access the specialist mental health services that CAMHS provides.

The HSE’s child and youth mental health office was established in September 2023 to consolidate, expand and accelerate our overall child and youth mental health improvement programme. Last year, the child and youth mental health office published a targeted action plan to ensure that all children and young people in Ireland have equitable and timely access to high-quality mental health services. The development of this three-year plan involved extensive engagement and consultation with young people, parents and families, as well as a diverse range of stakeholders in health, social care, community and education settings. The plan builds on the wide-ranging service improvement programme already under way and incorporates all recommendations arising from the Maskey report, the Mental Health Commission’s report on CAMHS provision and the audits conducted into prescribing practice and adherence to the CAMHS operational guidelines.

The final report of the north Kerry CAMHS look-back review was published on 18 February this year. This review was commissioned following concerns identified in the Maskey report, and includes all children and young people who were in the care of the CAMHS service in north Kerry on 21 November 2022. The report sets out how many young people who attended this team at that time were failed by the mental health services that were provided to them. On behalf of the HSE, I wish to apologise to any child or young person who has not received the standard of care they should expect. Building on these historical failures, the look-back review makes a number of critical recommendations. Importantly, these recommendations relate to issues already identified in the previous reports, which are now being addressed through the implementation of the child and youth mental health action plan. The findings also reinforce a key message that is coming through from our continued engagements with children, young people and their families, namely, the importance of addressing wait lists and ensuring timely access to the full range of multidisciplinary supports, including talk therapies.

The HSE’s action plan covers the full continuum of mental health supports, from prevention and early intervention through to specialist services in the community and inpatient settings. The overarching goal is to redesign and deliver services that are safe, effective and easy to access, and offer appropriate supports at all levels of need. This will require a co-ordinated response involving all aspects of the mental health system, including primary care, disability services and funded community partners, directed by national mental health policy and supported by multi-annual investment. There will be a need for continued improvements in staffing levels, service capacity and enhanced consistency in how care is delivered.

As part of this plan, a single point of access will be introduced across CAMHS, disability services, primary care and community sector supports, such as Jigsaw, Pieta House and the ISPCC. The rollout is ongoing, with full deployment this summer. This will ensure there is no wrong door for children, young people and families seeking support from the HSE. Alongside the single point of access, the HSE will invest significantly in building our capacity to conduct autism assessments and interventions. This will be supported by a national protocol, which will be launched in the coming months. Supported by digital health records and an integrated children's referral form, these are all initiatives that will make the referral pathway much simpler, faster and easier to navigate.

As was the case with the development of the action plan, it will be crucial that Ireland’s children, young people and their families are closely involved in the design, delivery and evaluation of mental health services. While there is still work to be done to reach the goals set out in the HSE’s action plan, a lot has been achieved since the establishment of the child and youth mental health office. Published in December 2025, the updated CAMHS operational guidelines set standards for high-quality care and will guide consistency in service delivery throughout the country. A full electronic health record with electronic prescribing is currently being configured for CAMHS and will be deployed regionally on a phased basis from mid-2026. Addressing a number of important governance issues identified in the Maskey report and by the Mental Health Commission, this will ensure automated data collection and improved data accuracy to ensure accountability, transparency and continuous quality improvement. There has been an expansion of crisis services, including through CAMHS hubs and now suicide crisis assessment nurse services for those under 18 years. CAMHS hubs provide brief intensive interventions to children, young people and their families in times of acute mental health crisis. A signposting platform, the Navigator tool, was developed in collaboration with SpunOut. This innovative web-based tool offers anonymous, immediate and personalised access to mental health information, resources and services tailored for youth mental health support.

Child and youth mental health will continue to be a key priority for the HSE, so we can ensure all our young people have the greatest chance to enjoy a healthy life and reach their full potential. Our work will be driven by a strong outcome focus and a commitment to report on progress in an open way. It is a complex undertaking, but building on our consultations and engagements with young people, their parents and staff, we are confident that we are on the right path.

I thank the committee members for the opportunity to update the committee on our specialist CAMHS. I am the assistant secretary with responsibility for social care, mental health and unscheduled care at the Department of Health. I am joined today by my colleague Ms Siobhán Hargis, principal officer in the mental health policy unit, and colleagues from the HSE.

I will outline the significant work under way across government to improve all aspects of youth mental health care, including CAMHS.

Our aim is to deliver a modern, responsive service that meet the needs of young people and their families. This is central to our national mental health policy, Sharing the Vision, our suicide prevention strategy, Connecting for Life, and the broader ambitions of Sláintecare.

Youth mental health supports span a tiered approach. While approximately 2% of children require the specialist care that CAMHS provides, the majority can have their needs met through early intervention, primary care and community supports. Over recent years, the Department has expanded investment in these early and downstream services. Under budget 2026, funding was provided to open two new Jigsaw early intervention services and develop five new discovery colleges for young people. We have also prioritised innovative supports that encourage timely help-seeking, such as the navigator tool launched in 2025 with the HSE and SpunOut, which provides young people aged 16 to 34 years with anonymous, immediate signposting to trusted mental health supports. For those who require the more intensive multidisciplinary approach of CAMHS, it is essential that access pathways are clear, consistent and streamlined.

Significant progress is being made through legislative reform, policy implementation and sustained investment. Both the Department and the HSE fully recognise the need to improve access to all youth mental health services, particularly CAMHS, and to reduce waiting lists amid growing national demand. Recent budgets have funded additional CAMHS activity, extra staffing for specialist programmes and innovative service improvements. These measures are delivering results. In 2025, 12% more referrals were accepted by the HSE than in 2024, while nearly 252,000 CAMHS appointments were offered to children and young people last year. Importantly, more than 90% of urgent referrals are responded to within 72 hours. We are committed to maintaining momentum this year, including modernising inpatient services, expanding digital responses and strengthening early intervention and community-based care.

CAMHS now receives approximately €190 million annually, an increase of almost 40% in four years. A further €127 million supports the HSE's partnerships with community and NGO organisations, many of which work directly with vulnerable children and young people. Ring-fenced funding of €3 million is dedicated to reducing waiting lists, especially for those waiting more than 12 months. We acknowledge that recruitment and retention challenges seen internationally also impact on services in Ireland. However, incremental progress is being made. Under budget 2026, the HSE is recruiting 300 new mental health posts, which will enhance supports, expand early intervention pathways, strengthen crisis responses and help ensure care is delivered effectively and appropriately.

In 2023, the Department funded the establishment of the child and youth mental health office, led by assistant national director Donan Kelly and supported by national clinical lead, Dr. Burke. A key milestone was the publication of the youth mental health action plan for 2025 to 2027, which we are closely monitoring to ensure full implementation. This plan focuses on ensuring equitable and timely access to high-quality care, with improved and measurable outcomes. Key reforms include developing a single point of access and more integrated crisis response pathways. This supports a shift away from siloed services towards clearer, more co-ordinated pathways for families, young people and front-line professionals, including GPs. We continue to strengthen cross-government collaboration, linking mental health with primary care, disability, childcare, education and youth justice. Crucially, lived experience and youth voices remain central to service design and delivery.

Revising the Mental Health Act and introducing a new Mental Health Bill has been a long-standing commitment under multiple programmes for Government, Sharing the Vision and Sláintecare. The Bill aims to strengthen and uphold the rights of people accessing mental health services, with particular benefits for children in inpatient care. For the first time, community mental health services, including CAMHS, will be regulated and inspected by the Mental Health Commission. The commission has already begun developing standards for CAMHS following a public consultation in 2025, with work under way to accelerate implementation. A significant development in the Bill is enabling 16- and 17-year-olds to consent to mental health treatment on the same basis as physical healthcare. This reflects our core values of respect, compassion, equity and hope. We look forward to the Bill's enactment later this month.

The Minister of State, Deputy Butler, and the Government have expressed deep concern regarding the recent north Kerry CAMHS look-back review, published by the HSE on 18 February. The review identified serious shortcomings in the care provided during a specific period that did not reflect national CAMHS standards or the commitment and professionalism demonstrated across the service. The Department continues to work closely with HSE regional and national offices to ensure all recommendations are fully implemented and best practice is embedded. Ahead of publication, the HSE ensured early communication with affected families and established a local helpline and a clinical liaison support team. There is clear evidence of significant improvement in Kerry since 2022, including stronger governance, regular care and prescribing audits, more standardised practice, a strengthened workforce and safeguards to prevent recurrence. The affected young people and families remain our priority.

I reiterate the Department's commitment to working collaboratively with the HSE and all stakeholders to ensure that every young person can access appropriate, integrated mental health supports at the right time and in the right place. We share the committee's determination to improve youth mental health care and access to CAMHS. It is vital that confidence in these specialist services is strengthened, as they make a profound difference to many young people and their families. We look forward to engaging with the committee today on how we can continue to deliver meaningful and lasting improvements in youth mental health care in Ireland.

We now move to questions from members. We will take a break before 11 a.m.

I thank the witnesses for coming in. I am familiar with CAMHS in Tallaght and I am quite complimentary of the service there.

Ms McArdle mentioned that recommendations had been made in previous reports regarding issues that were later identified in the Maskey report. How many reports does it take to do a job right? When the first report that identified issues was published, why were they not dealt with then? Will this report be successful in addressing issues? When it comes to children and their mental health the first report should have been enough. To hear that issues were identified in previous reports is a source of annoyance.

I note there have been significant improvements in Kerry since 2022. I would hope so. Anything would be an improvement on children's lives being destroyed and having children dealing with things that they will live with forever. I am so annoyed this morning reading through these documents and listening to the witnesses.

When the parents of a child who presents to CAMHS do not agree to their child taking medication, for example, for a diagnosis of ADHD, are they turned away and told their child cannot be taken onto CAMHS books, as such? Is that still happening? There was a time when parents of children with ADHD who decided not to go down the medication route were told by CAMHS that their child could not be seen. Can I get a yes or no answer? Is that still happening?

That is a clinical question. I will pass over to Dr. Burke.

I will take the second part first and return to the part about the reports. Anybody who fulfils the criteria for moderate to severe ADHD should be seen by CAMHS, regardless of whether they want medication. They should not be turned away by CAMHS if they meet moderate to severe criteria for attention deficit hyperactive disorder.

Are children turned away from CAMHS if their parents say they do not want to put them on medication?

They should not be.

It should not happen, but does it happen? That leads me to this thing with people in Kerry. Imagine bringing your child to a professional and being told that if you do not put your child on medication, they cannot see you anymore. Is that something that is happening? I want to know what is happening when parents are refusing to give their children medication, for whatever reason. It can be very daunting to put a child on ADHD medication. Some people may feel they are failing their child by putting them on it. It is a struggle. It can be a journey for them to come around to see that medication probably is the right thing. Are people being turned away if they say "No" to medication? Do they not get the services? Do they not get regular appointments?

I will come in there on an overall level from CAMHS. One of the things we talk about and have developed are multidisciplinary teams. Multidisciplinary teams include clinical personnel, such as medical doctors, but also psychologists, occupational therapists, and speech and language therapists. A full range of people are there to both assess and support the young people and then to support intervention. As Dr. Burke has said, it is not only medication; it is a range of interventions.

It is a journey; that is absolutely right. We always say to people that we will discuss the options with them but it is up to them and their child to decide when the option should be taken up.

Yes, but if a person says "No" to medication and they are allowed to park the medication, are they told they are still under CAMHS care and will be coming back for regular appointments, or are they told they should go to Jigsaw or somewhere else for therapy? What happens?

It can be a combined approach. We can talk about what we are working on in terms of the single point of access. We are working with our partner agencies to increase capacity across the whole system. It is not that people can attend CAMHS and they cannot attend Jigsaw. We are going to be working together and we will decide. For example, at the moment we are working with Parents Plus to do evidence-based parenting interventions for young people with ADHD. We know that if we can get in early in those cases, 30% of those young people will not go on to need specialist services. Therefore, it is a whole-system approach. I am not saying "well, you are attending CAMHS and you are not attending Jigsaw." That may be a very valid way of managing the young person, but they should not be turned away from CAMHS because they do not want medication.

I am still unclear on whether, generally, the process is that somebody who says they will not go on medication will be turned away from CAMHS. That would worry me. If I was located in Kerry and I was told my child was to take medication, I would be on the fence. I would be very concerned given what happened.

The answer to that then is "No". They will not be turned away from CAMHS if they say "No" to medication.

Was that not something that was happening?

There were anecdotal reports that it was happening to people, but the answer to the question now is "No".

I want to follow up on the €127 million in funding for partnerships. How much is going to the communities and how much is going to the NGOs?

From the overall amount of funding that is going into child and youth mental health services, roughly €15.6 million is going into voluntary and community sector organisations like Jigsaw and Pieta House, and a number of other providers such as SpunOut as well.

Okay, that is important. I thank the witnesses.

I thank our guests for coming in. Dr. Burke said in her opening statement that there has been a "decrease in the number of young people waiting 12 months or longer" for CAMHS. Where is she getting those figures from?

They are our own figures.

They are factually incorrect based on responses to parliamentary questions I have received. The waiting list in 2025 in total was 4,144. That increased to 4,232 in October and then increased again to 4,462 in December, from a base in 2020 of 2,115. In 2020, there were 223 children waiting longer than a year. That number has increased to 602, so where is this decrease Dr. Burke is referencing?

What we are talking about is the overall increase in demand. The figures-----

No, with the greatest of respect, the opening statement clearly refers to a "decrease in the number of young people waiting 12 months or longer."

Yes. That is in relation to the context between 2024 and 2025 where there has been a decrease of 3.5% in those waiting over 12 months.

However, there has been an overall increase of 170% in five years. Is the HSE nitpicking two figures from the last five years to justify saying to this committee that there is a decrease?

The Deputy makes a very valid point. The difficulty we have at the moment is actually around the increase in demand overall. Can I-----

Let me make this very clear-----

-----give some background and context? The waitlist is one thing. What we really want to see is young people being seen in a more timely manner.

I fully agree with Mr. Kelly but that is not what the opening statement states. The opening statement clearly refers to a "decrease in the number of young people waiting 12 months or longer."

That is in reference to the numbers between 2024 and 2025. I apologise if that is not clear in the statement.

It should have been clear in the statement because the information that is put on record to an Oireachtas committee needs to be factually correct.

I will move on to the 4,712 children seen as part of the €3 million ring-fenced funding. How did this come about if there have only been an additional 19 whole-time equivalent posts in the last three years?

Under the waitlist initiative, funding was given out individually to the regions. The regions are all running their own particular programmes to address those kind of long waits. I will hand over to one of our regional colleagues to speak about specifics because each region has done slightly different things. Some people are putting on clinics after hours; some are putting on clinics at weekends and I know there-----

Does the HSE think 19 additional whole-time equivalents is a necessary level of additional staffing, given the 4,000 odd children that are sitting on a CAMHS waiting list?

This speaks further to the issues around recruitment and retention within the services at the moment. We have worked on a number of national programmes. It has been really difficult for services, particularly given a lot of the media attention, in terms of retaining staff. We have worked at a national level around putting a spotlight on CAMHS. Most of us who have worked within CAMHS services, including Dr. Burke and me, appreciate that it is a really rewarding career but there is a negative perception about-----

It is also a challenging career.

Yes, these roles are very challenging.

I think we can all accept that.

There is certainly room in terms of further recruitment that needs to go into those posts. That is what we are trying to do at the moment in going through the regions.

On the issue of staff recruitment and retention, how many vacancies exist today in the 75 core teams?

Unfortunately, the HSE does not collect the overall national statistics through the HR system that gives an overarching view of all vacancies. What I can say is that since 2023 when the budgets were reset in the HSE, in CAMHS overall - CAMHS community teams plus the specialist teams and the inpatient service - there has been a 10% increase in terms of workforce.

Has the youth mental health action plan been fully resourced?

The child and youth mental health action plan is a three-year programme. What we have described within the action plan is what good looks like. We need to incrementally grow those services.

I asked whether it has been fully resourced.

We have received a number of posts over the past three years since the office was opened. I think we have 242-----

Is that those 19 additional whole-time equivalents?

No, 242 posts have been allocated overall as part of investment into child and youth mental health services. Some of those are into more specialist teams like those we have discussed, such as CAMHS hubs and the-----

I have a final question on staff retention and recruitment. How many of the 300 additional posts sanctioned in budget 2026 are going to go specifically to CAMHS?

Ninety-five of those posts are specifically for CAMHS.

I will move on. Clear pathways were spoken about, which would be absolutely welcomed by those in need of CAMHS services and by their parents, carers and guardians. One issue that consistently comes to me through my office is children who are told that they need an ADHD assessment and they are being refused that assessment by CAMHS because they also have a diagnosis of ASD. What is the justification for that and how common is it?

There is no doubt that we have work to do here. That is why we are bringing in the single point of access. It should not be up to a parent or general practitioner to try to navigate the system. Often these young people need support, not just from CAMHS but also from disability services or primary care services. Unfortunately, what has been happening is they were referred to CAMHS but did not meet the criteria, they went back again and were referred into disability services.

To be clear, I am talking about children specifically refused an ADHD assessment by CAMHS because they have a diagnosis of autism.

To make a definitive diagnosis of ADHD there would have to be a clear autism diagnosis.

These children have been diagnosed with autism.

Then they should not be refused for an ADHD assessment if they meet moderate to severe criteria.

On that topic, as clinical lead, will Dr. Burke tell me what I should go back and say to my constituents? Where is their next port of call when their autistic child has been refused an ADHD assessment by CAMHS?

If there is an issue, they need to come back to us because there is a clinical escalation pathway and we need to go back and look at it. Somebody should not be refused. We can go back to the original service or I can take the case myself after this discussion and have a look.

Who is the "us" Dr. Burke is referring to? I am talking about children who have been repeatedly referred to CAMHS and are being told that they are too complex, that they cannot be assessed or treated through primary care services or CDNT. They are being told that the only door they should go to is CAMHS for an ADHD assessment and they are being refused because of an autism diagnosis.

As I was trying to explain, we are trying to ensure that the services will work collectively to do that diagnosis, so that it is not just CAMHS or CDNT. In a specific escalation process, it needs to go back to the regions, to the clinical director of the service to have them look at that particular issue for a young person.

How common is it that CAMHS refuses to see an autistic child for an ADHD assessment?

I ask for a brief answer because we are running out of time.

I have seen issues coming through but I cannot give an exact figure.

Is that data correlated?

We have data on the number of young people who do not meet the criteria for CAMHS but we have not broken it down by diagnosis.

Will that be done?

Yes, with the electronic patient record and the single point of access later this year, we will have that data.

I welcome all the statements. The Maskey report and the look-back review make for alarming reading. Staffing and resources and recruitment and retention challenges have also been highlighted. There were two apologies in Dr. Burke's statement. The first was, "I wish to apologise to those who have experienced shortcomings in accessing our services". The second apology was, "I wish to apologise to any child or young person who has not received the standard of care they should expect". It also stated that there is clear evidence of significant improvement in Kerry. I am a proud Kerryman, from north Kerry. The latest report is damning and it has been very hurtful. The HSE says there is clear evidence of a significant improvement in Kerry since 2022.

I will give one example. A 14-year-old autistic child, recently diagnosed with anorexia, was admitted to University Hospital Kerry for a prolonged period due to a dangerously low body mass index, BMI. The child has since been diagnosed with anorexia and associated medical risks. During this admission, the family reported significant gaps in appropriate care. The hospital did not have autism-informed supports, and essential allied health professionals, including a paediatric occupational therapist and a psychologist, were not available on site. This left the family to source private therapy outside the county while still managing an inpatient stay. The child also required specialist paediatric oversight from a consultant with experience in autism and eating disorders. Multiple referrals to external consultants were declined due to lack of ASD supports, especially cross-county - I am referring to Cork - and long waiting lists extending to 2026. As a result, the child was discharged without a clear care plan to access the specialist medical oversight required for both autism-related needs and anorexia treatment.

These challenges are compounded by wider capacity issues in the region. Eist Linn and CAREDS, the child and adolescent regional eating disorder service, provide key services for young people with eating disorders. Both have reported staffing shortages and limited availability. This means that children with complex presentations, such as autism combined with anorexia, face significant barriers in accessing timely, appropriate and co-ordinated care across the system. The case I raise highlights systemic failures in staffing, autism training, service integration and the availability of specialist eating disorder supports, leaving families without a clear or safe treatment pathway. This is occurring post 2022, whereas the HSE is stating there have been improvements since then.

What medium-term actions are being put in place to address the wider gaps in autism-informed care, eating disorder capacity and cross-county service pathways - these are very important - that have left this family without any appropriate treatment route?

I will take that question and hand over to colleagues in the south-west region in terms of the experience. We will not comment on individual cases, but in terms of policy development and investment, there has been investment in CAMHS and in specialist teams. Those specialist teams are there to-----

With all due respect, that has been stated. My case has arisen since 2022. The figures for everything have increased, bar for the service.

We are committed to enhancing services. In the medium term, it is a Government priority to enhance those teams.

I will hand over to Dr. Phillips to address the experience in the south-west region regarding integration. Before I do, I will say that at national level in the HSE the autism protocol has been developed and our colleagues in the child and youth mental health office will be able to speak about how that integrates for young people with CAMHS needs.

Much has been done but much more needs to be done. We have some of the longest waiting lists and waiting times in the country in our CAMHS services and we are determined to resolve this.

Sorry for cutting in. Is that a question of staffing or resources? Let us put our cards on the table here. What is it?

No, I would not say the issue is entirely to do with staffing. There are a number of things. We have some very hard-working teams. There is also a need to improve productivity in some teams and also to introduce new models of care. We have other colleagues who are going to help us with some of this work. General practitioners, community medical officers and others with training are going to be very helpful in this work. The big deficit we have seen in staffing has been in consultant psychiatrists. We have some good models of care with telemedicine but I acknowledge that we have some gaps and my personal responsibility to resolve them.

To echo what Ms McArdle said, we cannot comment on the particular case the Senator raised. However, it highlights the complexity of, and the requirement for, an integrated care approach for children, regardless of diagnosis or the clinical need from a consultant perspective or a health and social care perspective. In the south-west region and all of the regions, we are now stepping up our integrated care services and we will have much more scrutiny of the individual cases because of additional staff and more robust governance. The case the Senator raised highlights the requirement for all parties, whether they work in the acute hospital, Eist Linn or the community services, to integrate in order to support the child in question and the wider family. That is our approach on integrated care.

I hear the Senator when he says that his case has happened since 2022 but, as Dr. Phillips said, we have had improvements. We are on a journey of improving integrated care and trying to encourage clinicians to work together with the patient and family at the centre, not within the silos of acute care and community care.

One thing to highlight in the context of the system is that if everyone involved has the wheels up and is going in one direction, everything should be okay going forward.

Correct.

On CAMHS, it has been a case of report after report. The findings in this regard have given rise to soul-searching on the part of the HSE and the families. As Senator Costello stated, one of the findings in the report is that all the children who were being medicated at the time were not accompanied by adults. I hope that will be something we learn from. It is disturbing to hear about children under the age of 16 who have mental health issues being medicated without an adult or guardian being present. The report in question highlights serious clinical governance and oversight failures in the care of children and adolescents in my region, with clear risks identified for vulnerable young people. Given those findings-----

The Senator is out of time.

I am out of time.

We might get a second round in later.

I have a number of questions. This is our second session on CAMHS. The first session was very concerning in the context of what we heard from families, particularly Families for Reform of CAMHs, about their continuously feeling that they have to fight to access services and about vulnerable children falling through the cracks despite their parents' best efforts. We also heard about the postcode lottery relating to services and there being longer waiting lists in some regions, including Cork and Kerry. In the interim, another report has been published. The latter is in addition to the two previous reports and contains a long list of recommendations. I am deeply concerned about where we are at, having heard the evidence from the families and seen the reports. I want to focus on those reports. Are the HSE and Department of Health confident that the problems identified in south Kerry in the first instance and then in north Kerry are not being replicated elsewhere?

I might come in on that initially. The Maskey report was published in early 2022. It contains a series of recommendations, but one of the findings highlighted a concern regarding care in north Kerry. That is what precipitated the look-back review in north Kerry. Concurrent with that, the Minister of State, Deputy Butler, asked the HSE to undertake a medication audit and also an audit of every CAMHS team across the country in order to ensure the findings of the Maskey report were not replicated or evident in any other CAMHS area.

Was that based on the prescribing practices or was it based on the wider issues around governance and diagnostics?

It was on both. There were two separate audits. There was an audit regarding medication and prescribing practices and a separate audit in respect of governance, compliance with guidelines and standards of care, as would be expected in a multidisciplinary team.

Would the HSE share that position?

Yes. The results of the prescribing audit were very reassuring. While there was a 79% rate of prescribing in Kerry, the rate nationally was 39%. We are not complacent on that. Each region is conducting ongoing audits. When the electronic patient record is forthcoming at the end of this year, we will be able to step up national audits again. However, those results were quite reassuring.

The north Kerry report contains 61 recommendations. Have they all been accepted?

Yes.

In the HSE's opening statement, reference is made to the fact that recommendations in the Maskey report in respect of south Kerry and the Mental Health Commission report have been incorporated into the youth mental health action plan. Will the 61 recommendations relating to north Kerry be included in the action plan?

They are already addressed within the action plan. Essentially, the findings were very similar to what was found in the Maskey report. It was really an extension of that, so they have already been incorporated. Much work has already been done.

Has the action plan been updated since the report was published?

No, because all the recommendations are already contemplated within the action plan.

How is the HSE monitoring the implementation of these recommendations? A concern has arisen, not just at this session but also at previous ones, to the effect that reports are published and recommendations are made but there is then a failure to implement the recommendations. What assurance can the witnesses give that these 61 recommendations, along with the others, will be implemented in full? How is implementation being monitored?

I will ask Mr. Kelly to speak to that, because we have a robust process in place.

Out of all those reports, there were 164 recommendations. We have distilled these down into the 16 key actions around the action plan. Many of them relate to oversight and governance. Over the past year, we have worked on one of the key recommendations, which is the introduction of an electronic health record. That has been talked about for many years, as people will know. We built a business case and, secured funding, and the first region will go live with that in July and it will then be rolled out to the rest of the regions. That has in-built improved governance standards around it. It also has an e-prescribing function, which will flag if there are particular issues around prescribing. There is also a full suite of audit processes.

On the single point of access, we have been involved with three exemplar sites over the past year and a half in terms of developing the operational policies for that. As the committee will know, the CEO mandated that a single point of access across all children's services be implemented in October last year. We are working across areas such as disability, primary care and our voluntary and community sector partners, like Jigsaw and Pieta, to introduce that. The electronic health record will help with the single point of access because we will have an integrated children's service referral form. As a result, there will be no more bouncing between services for young people. Everything will be done in the background.

That policy is very welcome. We have been informed about increased accountability following the publication of the north Kerry review. How will we see that accountability? What will it look like?

Accountability comes through the devolved nature of the regional health areas. There is a whole governance structure which sits within that, as well as the national plans. Each of the local IHA areas and regional health areas have their own service improvement plans for any issues which arose out of the Maskey and Mental Health Commission reports.

Has anybody been held accountable for the failings identified in the report? If not, will they be?

The findings were partly individual in nature. The individual clinician involved has been referred to the Medical Council. Every clinician is accountable for their own practice, so that accountability trail will take place. There is also a governance issue more broadly which the organisation needs to be held accountable for. The clinical governance arrangements and framework are changing. The entire structuring as to how the clinical governance works has changed. A change has also been made in the context of recognising that the nature of multidisciplinary team work is much more important than individual clinical decision-making. All of those things have changed, and there is individual accountability and organisational accountability.

Is Dr. Phillips happy that there has been a level of accountability in the context of the findings?

Absolutely. The appropriate actions have been taken in respect of the individual clinical accountability.

The 2023 Mental Health Commission report contains 49 recommendations. How many of those have been implemented?

The recommendations arising out of the Mental Health Commission report were considered as part of the child and youth mental health------

The question is how many of the 49 were implemented. The report was published in 2023. Three years later, how many have been implemented?

We will have to come back on that.

We will have to come back to the Chair. As we discussed with the Mental Health Commission, we would not be reporting on the specific recommendations because many of the themes from all the reports were very similar. We have tied them up into the 16 key actions.

This was raised at our previous session. If the witnesses saw our last session, Families for Reform of CAMHS identified a lack of transparency around the implementation of those recommendations. Hopefully, the witnesses will provide an update in writing on that matter.

We will certainly come back to the committee on that.

I thank all the witnesses for attending. I want to start by asking about urgent cases and how they are processed. Reference was made to about 96.3% being processed in three working days. That is wonderful. What are the figures for the south-west area and the Dublin and north-east area? Obviously, we know the waiting lists there are substantially greater than in other parts of the country. Can the witnesses provide those figures, please?

The figure in terms of urgent referrals is 93%.

So if I go to my GP in the south west and that GP identifies that my child needs to be seen by CAMHS, my child will be seen within three days in the south west.

Based on the urgency of the presenting clinical factors. If it is deemed urgent in terms of the clinical operational guidelines, we are meeting that KPI 93% of the time.

And across all the other regions in the country.

I do not have the individual figures to hand but, yes, the national average is meeting the overall target.

Would Mr. Kelly accept that, because we are seeing serious differentials among the waiting lists in some areas, that figure might vary dramatically?

I may stand corrected on this, but not to my knowledge, and I have looked at the recent KPI reports. All regions are meeting that standard.

An important part of the KPI process is to feed back to the witnesses that I believe there is a serious crisis of confidence in some parts of the country with regard to the operation of CAMHS. When I talk to GPs serving some of the most disadvantaged communities both in my constituency and in Dublin West, they tell me they dread having to refer to CAMHS. They feel it is a black hole and they do not know where those referrals go to, so they will go to Crosscare or do something else but they will do their level best to avoid referring to CAMHS. It is wonderful if the children who are referred are seen within three working days, but that message is not being conveyed to GPs on the ground, who are seeing some critical cases of young children.

I also want to ask about Jigsaw. I talk to Jigsaw, and we know there is a hugely inconsistent pattern across the country with regard to the relationship of Jigsaw referring to CAMHS. Jigsaw has told me that in some areas the relationship is wonderful and in other areas it is talking to the wall. What comfort or reassurance can the witnesses give me and Jigsaw, and indeed families across this country, that work is being done to improve those pathways?

I can give the Deputy reassurance on that. We have been working very closely with Jigsaw on the single point of access. Jigsaw will be part of the single point of access. It is on the health link referrals now, but also we will have clinical meetings with Jigsaw in order that we will be in a position to discuss cases. It will have a rapid escalation pathway because that is what is really important for Jigsaw. Jigsaw can take up mild to moderate cases, but then if it runs into a clinical challenge with somebody who is suicidal, we do not want it to have to go back to the GP. It will have a rapid escalation pathway through the single point of access into CAMHS in that area. We will also have data-sharing agreements and memorandums of understanding that will give a comfort to both clinicians-----

As of today, I believe Jigsaw would say that it does not believe that those care pathways are in place. When does Dr. Burke expect that those care pathways will be in place?

The single point of access will be stood up across the country by the middle of this year, but we are working closely not only on our exemplar sites but across the area with Jigsaw. We had a meeting last week with it and all our voluntary and community partners. We do recognise that relationships are very good in some parts of the country and less good in others. Some of that is about the data sharing and being able to talk about young people, so we are developing those nationally to support this.

May I ask Dr. Burke about staffing? What is the current CAMHS staffing shortfall at this point in time?

I will hand over to Mr. Kelly because he has the figures with him.

It is a difficult one. We do not have a national set of standards in terms of the staffing overall. It was always envisaged that each CAMHS team would have about 13 members of staff. The teams vary between four and up to 20 nationally.

So ballpark?

Ballpark, overall, in terms of the 75 teams, I think there were about 69% of what was envisaged in terms of staffing. That is a mixture of both vacancy and funded posts.

I want to ask about the model of care on eating disorders. We understand there is a gap, a shortfall, of 61 posts with regard to CAMHS care and eating disorders at this point in time. That is what I understand from the reply I received from Dr. Niazi to a parliamentary question at the end of January. May I just be clear that the Department agrees with and stands by the 2018 model of care? In the letter to me Dr. Niazi states that there is an increasing complexity of care and, of course, population increase. Does the Department plan to update that model of care?

The Department is fully committed to the full roll-out of that model of care. This year will represent the full roll-out of access across all regions, with 16 teams to be in place by the end of the year.

So the shortfall of 61 will be filled by the end of this year.

We will have 110 clinicians working directly in specialist eating disorder teams nationally, up from five of those teams in 2018. Each team is allocated an initial ten staff members to achieve national coverage in the first instance, so we will have approximately 160 staff allocated to eating disorder teams across the country.

So there will be 14.4 whole-time equivalents for each CAMHS team per 500,000 to 600,000 of population across the country, and Ms McArdle is telling me that will be fully committed to by the end of this year.

It is approximately ten WTEs per team.

That is not what the model of care says.

I can come in there, if that is okay. In order to reach national coverage, there is a phased approach to standing up the team, so some of the teams may start with a smaller number of WTEs to begin with, and as each branch progresses we will increase-----

I accept that, but it is not true to say that the full complement will be there by the end of this year.

The full number of teams will be funded and will be in the process-----

But it is staff. We can have all the teams in the world but if we do not have the number of staff, that is the critical point.

The last point I will make in the few seconds I have left is to the Department. I do not see any real reference in its opening statement to primary care. There are 22,000 children waiting six months or more for access to primary care psychology services. Surely that has to be part of the conversation in terms of reducing the pressure on CAMHS. It is great that we have the resources we need and early intervention into Jigsaw, and I fully support that, but to my mind there is a big hole in the middle right now and I do not see the Department of Health putting its shoulder to the wheel in resourcing primary care psychology services.

Thank you, Deputy. We will just get a brief response from the Department if you wish.

We agree that mental health is a tiered model, and primary care is a really important part of that. There are exceptionally long waiting lists in primary care, and this year funding has been allocated to address those long waiting times. In addition-----

Thank you. Unfortunately, we are over time on this slot.

But, sorry-----

We are over time, Deputy, and we will stick to time in the interest of fairness to the other members. We want everybody to get in so everybody has been allocated the same amount of time. You have actually been allocated more.

I am into and out of the disability matters committee so I apologise. In that context, if I ask something that has already been addressed, again I apologise in advance.

I just want to declare a slight conflict of interest. Dr. Burke and I go back a very long way, so I will try to avoid directing any questions specifically to her, but if she wants to come in on anything, I would be delighted. I congratulate her on her national role. I know it is a very difficult appointment.

I heard Ms O'Neill last week on RTÉ, I think. It was confirmed that there were no consultant psychiatrists with higher specialist training in north Kerry CAMHS. I want to direct that to the REO. Is that still the case?

No. We have three consultant psychiatrists in north Kerry and two in south Kerry and they are on-----

Are they there permanently?

They are on temporary contracts. It has been exceptionally difficult to recruit to the permanent-----

How many of those have higher specialist training in child and adolescent psychiatry?

They are all on the register.

With higher specialist training.

Yes, correct.

I might establish that not to be the case. Last week, at the disability matters committee, we had here a hospital consultant who revealed that he was carrying out clinics in CAMHS in Galway and he had no higher specialist training in CAMHS. I understand that many consultants have higher specialist training, but in psychiatry do they have the higher specialist training that is appropriate for the post?

Take the case last week, for example, where a consultant was working in a clinic where he had no specialist training in that regard. Ironically, he was here to talk about standards and governance. For example, you would not have a urologist do a cardiothoracic clinic or someone from plastics try to do a hip replacement, but it was clear from the Maskey report and from the north Kerry CAMHS report that the HSE is appointing consultants to positions with no higher specialist training and they are inappropriately prescribing and medicating children and sedating them, chemically imprisoning them. I appreciate the apology from the HSE that they did not receive the standard of care they deserved but what happened to them is consistent with offences under the Non-Fatal Offences Against the Person Act 1997, which are criminal offences. Can the witnesses tell me how many consultant psychiatrists with the proper higher specialist training in CAMHS are in the HSE South West?

My understanding is they all have the higher specialist training and are on the register-----

Can Ms O'Neill write to me and confirm that? I very much doubt that to be the case. In fact, I know it not to be the case. If Ms O'Neill is going to come in before an Oireachtas joint committee and talk about CAMHS in light of what has happened to all these families and the concerns that have been highlighted by my colleagues, we need to be really specific. If I got on an Aer Lingus plane in Dublin Airport and the pilot said, "Welcome aboard, everybody. I have done a few hours in a Cessna. I am pretty confident I can get this plane to London. Sit back, relax and put your seat", I would get off the plane. I know that all over the country, because I do not think this is confined to Kerry CAMHS, there are people appointed to posts in psychiatry who have no higher specialist training. You do not find that in other disciplines. It does not happen in surgery – except, ironically, in the case of CHI – nor does it happen in oncology or general practice, so why is it happening in psychiatry? You can see straight away the damage and the harm it is doing.

I agree with the Senator. We recognise that consultants were being employed who were not on the specialist register. There has been a very robust governance piece around that. As I understand, all the consultants that are inputting into Kerry are on the specialist register, it is just that some of them are sessional and some of them work part time. It was in terms of the whole spirit of what we would understand, which is a permanent consultant who is there every single day of the week, every week of the year, which is the model we aspire to, that my comments were in relation to. In the past it had been incredibly difficult to recruit consultants but the new consultant contract, POCC 2023, has done a lot in that regard and we only have 17 vacancies in CAMHS at the moment. Across the country there are some people who are not on the specialist register. They have to be signed off directly by the regional clinical director in those areas and supervision arrangements put in place. There has been a very aggressive and targeted recruitment campaign to get people on the specialist register.

I thank Dr. Burke. On that, she mentioned permanent, fully qualified, on the higher specialist register consultant psychiatrists in post, in situ, there all the time. How many of those are there in HSE South West who are permanent – not sessional, not part-time, not feeding-in and not doing it remotely? I have heard of some consultants doing clinics remotely from the Middle East and from the Gulf states and maybe they might come back now on Helen McEntee's plan. How many of those does HSE South West have?

Within the CAMHS south-west region we have a total of 13 consultant psychiatrists.

And they are all permanent, in location-----

No.

Okay, so my question is, on the ideal that Dr. Burke set out, how many permanent, in-post consultant psychiatrists with the proper higher specialist training in CAMHS are in HSE South West?

We have 13 permanent and two filled on a temporary locum basis. That is a total of 15.

That is 15, and is Ms O'Neill telling me those 13 are consultant psychiatrists who have done the higher specialist training in CAMHS?

That is my understanding but I-----

No. Is Ms O'Neill saying "I don't know"?

No. I am of the opinion that they are based on the recruitment checks that we do as part of our people function and our-----

Will Ms O'Neill write to me to confirm that and provide me with the evidence to support that? I am aware there are people serving on the college of psychiatry in supervision and leadership roles who have no higher specialist training whatever in any area of psychiatry. I am very concerned that the damage that has been evident and the harm that is being done in north Kerry CAMHS is being replicated throughout the Republic. That is a matter of grave national concern but it is also of international significance.

I suggest that at this point we take a five-minute break. Is that agreed? Agreed.

I thank Dr. Burke, Ms McArdle and the witnesses for coming here today. I have to be honest; I simply do not recognise the service the witnesses are describing. I will pay tribute to the many fine people working in CAMHS but access to CAMHS is simply unacceptable. It is difficult not to be frustrated with some of the commentary. I do not know if the reports really reflect the amount of anger, frustration, pain and suffering of families 365 days a year who have been waiting for years to get access to a CAMHS assessment. It is the only service in the health service where an experienced GP makes a referral and it is rejected without seeing the patient. It is simply not good enough.

I will outline two pathways. An 11-year-old boy's family were in with me during the week. It is going on since he was three years of age. He has issues in school and there is a question of ADHD. I am not going into the details; it is not my job. He possibly has autism. They did all the family support stuff and went to the primary care occupational therapists who said this is ADHD or perhaps there are symptoms of autism. A referral was made to CAMHS five years ago. It said there were elements of autism and he needed assessment. Eventually, he got to see the psychologist in the primary care team who made an assessment in May 2025, six years on. He assessed him as not having autism based on insufficient evidence but felt he had complex ADHD, ADHD-C, and said he needed to be seen by CAMHS. There was a referral again by the GP to CAMHS. CAMHS sent out a form; it had not seen this boy yet. No one in CAMHS had seen this boy. The family had fill out an SRS-2 form, an observational form. It went back to CAMHS and guess what? CAMHS said after all of this it felt he had autism and he needed to go back to the psychologist for a re-assessment. This is absolutely ridiculous. There is a mother crying in front of me. Five years in, she wants her son to have an assessment in case he has this complex ADHD. I am not an expert in this but this is chaos and goalkeeping not problem-solving. There are families at the end of this type of service. By the way, they paid for an educational psychologist who came up with a diagnosis of ADHD. It cost €500. They were lucky to get it so inexpensively. Occupational therapists are saying this in the service. I am conscious of time but I need to get this off my chest.

In another family, a 15-year-old with autism was referred to CAMHS two years ago. I do not recognise what Dr. Burke said about CAMHS refusing autism. It is clear to me and it is consistent among Deputies, GPs I know and families I meet that if autism is introduced, it is like a goalkeeping situation. CAMHS puts its hands up and says, "No, we are not even seeing you and we are not assessing you." The other issue is sending out these patronising letters with common-sense parenting programmes for children with really difficult issues, gaslighting parents. Two years ago, the 15-year-old was referred with depressive symptoms. I am not going to go through all the other referrals they had to go to CAMHS in that area. Eventually they were seen in October 2025, two years into it. There were a number of engagements with CAMHS in Roscommon. They were then referred on for an additional assessment in Galway. The parents felt they were being told these were parenting issues. They turned up in Portiuncula hospital in February suicidal. They were kept overnight, sent home without a CAMHS assessment, seen by CAMHS again, then the father - these are very reasonable parents - found a detailed suicide note and then the child was admitted to CAMHS. They spent ten days in CAMHS in Merlin Park Hospital. These are the pathways that are the reality for parents and children, not what it is in this report. We see the waiting list of 4,462 children, which does not include referrals that have been declined by CAMHS. In Roscommon, 60% of GP letters were declined without seeing the patient. It is difficult not to feel frustrated.

I understand the other Deputies and Senators here because these families are coming into our offices non-stop, but I am also seeing it as a GP. Are the referral criteria for CAMHS too narrow?

First of all, we agree with the Deputy that more needs to be done. We can tell the Deputy how we are going to do it.

Just to interrupt, I would accept it if CAMHS in Galway or Roscommon said it did not have the capacity. Do you know what happens to this child on the border? CAMHS Roscommon sees him and he goes into a unit in Galway. He needs an assessment of need. They will not let the Roscommon assessment of need officer do it because the child is in County Galway on the border. There is no assessment of need officer in Galway. He is an inpatient. Now, you are purchasing one from the private sector in Mullingar. The child will be driven through Roscommon to get to Mullingar.

I am not making this personal but people need to recognise the problem. Parents on the ground and the children feel that the significance and size of this problem is not being adequately recognised. If someone in CAMHS turned around and said to a GP that CAMHS did not have the capacity to see that child, that would be fine, but do not tell me, as a senior GP, to go to Jigsaw, go to family support or go anywhere else. Many of those services simply are not available.

May I tell the Deputy what we are doing about it? I agree with him. It is unacceptable that the referral is sent back to him. Through the single point of access, the GP will make the referral. If CAMHS thinks the patient also needs to be seen by the CDNT or somebody else, it does not go back to the GP. It goes through the clinical triage forum to be accepted by the other agency. The GP will then receive a letter to say exactly what we are doing with their patient. Should they need further intervention, it comes back to the clinical triage forum to be discussed and that intervention is provided. It never goes back to the primary referrer.

For example, a HSE primary care psychologist says this child has complex ADHD and needs to be seen by CAMHS. This is five years into this process, not just two or three months. I have all of the rejection letters from CAMHS here. They are patronising, to say the least. CAMHS says "No", not on seeing the patient, but based on an assessment of a form. It decides it will not see them and they need to go back to the GP. There is no choice, by the way. There is only one psychologist in the service.

I thank the Deputy. I remind members that if we want to get answers from the witnesses we have invited, we need to allow them time to answer the questions as well and give adequate space. In the interest of fairness-----

I agree but I think they understand exactly what I am talking about.

I am just saying to the Deputy that, in the interest of fairness, we have invited people here and we need to give them time to adequately answer the questions as well.

I welcome all of our witnesses. I might start with Dr. Burke. I have read all of the reports about north Kerry CAMHS, including the most recent report. It seems to be that whatever about the policy, the practice was to medicate, medicate and medicate. There was certainly an overuse of medication as well as inadequate supervision. There were also issues around poor access to therapy and inadequate physical health interventions and supports. There was a huge amount of failure right across the board. I assume Dr. Burke accepts that, first and foremost.

We do.

I am not looking for a name, but for the office the person held. Who was ultimately responsible for north Kerry CAMHS when all of those failures happened?

I will ask the REO from the area to answer that.

If you look at that period of time, CAMHS reported into the head of mental health services. The governance rested with the chief officer at that particular time. The timelines for both the Maskey and Halpin reports are pre 2022.

I understand that. I am saying that this was allowed to happen and that it happened for too long. There was a policy of overmedicating children. Others have talked about the consequences of that and the report has identified the consequences of that, including the potential harm and risk to children. Is it the chief officer who was responsible for that poor oversight and lack of governance or was it the head of mental health services?

This was about prescribing practices. As we referenced earlier, clinicians have autonomy in terms of their prescribing practices. The accountable person is-----

There is autonomy but there is also good practice. I am now asking for the third time. When we are trying to get accountability, we need to know who was responsible for what. We are a long way away from the report being published. This has been debated upside down and inside out. It should be fairly easy to say that there was a consultant who was overprescribing children, there were mistakes made, there was a lack of supervision and it was not picked up on. Who was responsible for not picking up on that, operationally on the ground? I am not asking for a name. I am asking for the title of the individual who was responsible at that time for making sure this was not happening.

At that particular time, it was part of the former community healthcare organisation structures.

I am not talking about structures. I am talking about the title.

I know but the titles of the professionals and managers come from that. There was the overall chief officer and the head of mental health services-----

Are the head of mental health services and chief officer from that time still in post or are they somewhere else?

No. That has changed since then.

Are they still working in the health service?

My understanding is that one has left their position and the other person is working in another area.

I now want to come to the issue of how many full-time and whole-time-equivalent consultant psychiatrists we have in Kerry. Every time the question is asked, we seem to get a different answer. It might be more complicated than I would have thought because the question is straightforward. There are two teams in Kerry. Am I right in that? There are north Kerry CAMHS and south Kerry CAMHS. I am asking about the total number for both. We will break it down in one moment, but in terms of both of those teams, how many whole-time-equivalent, full-time consultant psychiatrist positions are there?

In north Kerry CAMHS, there are three consultant psychiatrists. They provide the equivalent of two whole-time consultant psychiatrists. They work a mixture of full-time and part-time and provide additional evening clinics-----

I will just ask my question again because I am trying to break this down to make this very simple for me. Across both of those teams, and leaving aside the number of consultants who might be filling those posts, how many whole-time-equivalent posts are there?

There are two in north Kerry and 1.7 in-----

So, there are three?

No, there are two whole-time-equivalents. Three consultants make up those two whole-time-equivalents.

There are two whole-time-equivalents in the north. How many are there in the south?

There are 1.7 whole-time-equivalents in south Kerry.

There are 3.7.

Correct.

Within that 3.7, how many consultants are providing those services?

Seven consultants provide them.

Okay. There are seven consultants providing a service through 3.7 whole-time-equivalent posts. How many of those are permanent?

None of those is permanent.

Not one? How many of those are done remotely?

The majority are. In terms of the north Kerry consultants-----

Let us break down the seven. We have established that we have 3.7 whole-time-equivalent posts and seven consultants filling those posts through a combination of contracts, temporary contracts, part-time, remote, assisting or whatever it might be. Of those seven, how many are providing services remotely?

There is a mixture.

I know that but I am asking how many of the seven are providing services remotely.

I will take one particular consultant, to give an example of the mixture of services and whether they are on site or practise telemedicine. One consultant provides telemedicine services three weeks of the month and is then on site one week of the month. It is the same with the clinical lead-----

How many of the seven are not on site at all?

I would have to come back with the exact number.

Is it more than one?

Yes.

Is it more than two?

Yes.

Is it more than three?

Probably 60% of them. I would have to-----

It is 60%. Now we are getting somewhere. This is what I am trying to establish. We have 3.7 whole-time-equivalent positions, which would clearly be inadequate even if they were in permanent posts, which they are not. We have seven consultants filling those posts, the majority of whom are actually providing a remote service.

Does Dr. Burke accept remote services are - I will not say suboptimal - but certainly not the same as a consultant working on the ground?

I would say that. Unfortunately, across the world, not just ourselves, it is difficult to get fully qualified consultant child and adolescent psychiatrists. There are large parts of North America that do not have any consultants on-site. Telemedicine is an acceptable alternative but young people have told us they find it more difficult to engage with somebody remotely - not always but sometimes.

Did the Halpin report agree that telemedicine was as good as on-site?

No, I am not saying it is as good as-----

You said it was acceptable.

It is acceptable but it is not as good.

In that report, is it accepted that the majority of those posts are filled by people providing telemedicine off-site? Would Dr. Burke argue the report is saying that is acceptable?

I would say that Dr. Halpin's report is saying it is optimal to have people on-site.

Exactly.

Aggressive recruitment has taken place. I understand a candidate has been identified and has been offered the post. What I am saying is that consultant recruitment is difficult. It has really improved since the public-only consultant contracts.

Can we get a note breaking down exactly what those 3.7 whole-time equivalent posts are and exactly what they are providing - remotely, on-site or whatever? Every time it has been asked, there has been a different answer. There has been some clarity now but more needs to be given on what each consultant is doing and not doing on the site.

It is a good question. Is Dr. Burke happy to provide that to the committee?

Yes.

Thanks very much.

I do not envy the witnesses their task because their work will never be done. We all accept it is a very challenging space they are trying to manage. I listened with interest to both opening statements. One has to accept there are genuine ambitions to improve the situation and give people easier and quicker access to services. That is worth noting. It is also fair to say the need is increasing every other day. There are more and more people presenting. It is against that background that I said the work will never be done. It is about predicting what the witnesses will need to firefight with.

Typically, what engages me a lot is when people come into my constituency office. In the past two weeks, three cases presented to me. Two were mums who cried bitterly. It is not easy to be sitting there, like I was, trying to understand what I could do for them. Those two cases were almost identical. The other case was an adult case. For an eight-year-old child in school, with the school working tirelessly to support him or her, there are days when it is very difficult and days when it is less difficult. The parents very rarely get a full night's sleep. This special child needs to go to school. The parents want a diagnosis but seem to be pushing doors without getting results.

When it comes to diagnosis and parents presenting their children, I always advocate for such a thing as a one-stop shop. A single point of access was mentioned earlier. Mother of God, there is nothing more frustrating for any parent. That is the reason the tears fall. They cannot get access to what their child is pleading for. They want to do the best for him or her. This is a bit of a story but it is like "Judge Judy" - real cases, real people. We do not want the same delay; we want intervention. When that parent of an eight-year-old child was sitting in front of me pleading for a diagnosis, what answer should I have given?

It is heartbreaking. As a clinician, I am in front of parents all day. It is a whole-system approach that needs to change; it is not just about CAMHS. That is what we are trying to bring in with single point of access. We know from jurisdictions that have brought in single point of access that if you work with voluntary and community partners like Jigsaw, Pieta and the ISPCC, there is a 30% decrease to statutory services. We could have a whole-system approach where we all talk together and co-ordinate. You send in one referral through one referral pathway but we all talk together behind the scenes.

Parents say to me they do not care who sees their child as long as long somebody sees their child. We see it as our job to direct that appropriately. CAMHS is a specialist service for approximately 2%. That does not mean the other young people do not need help now but it is up to us to decide where the most appropriate person is. We have to say that for a mother it is not acceptable for her child to wait. We need to get them to the right place at the right time. That might be multiple places. That might involve parenting interventions while waiting. We know they are evidence based and they work, particularly for young people with autism spectrum disorders and ADHD. It might be online interventions. We have put significant investment into digital interventions, so there is active waiting. Then when they get into the system, they should be seen by the most appropriate person or people. Sometimes it is not CAMHS or the CDNT; it might be both of them. With Sláintecare we are getting back to a population-based approach where people sit in the room together and do joint assessments so people do not have to go to one appointment and then another appointment.

It is whole-system reform and it takes time and continued investment - not just investment when there is a crisis or when a report lands. We need multi-annual investment because that is the only way we can get recruitment strategies. We need to know year on year we will get sustained investment so we can go back to the universities and tell them to train the specialist people we need. It is a whole-system approach. It is not just health; it is across education and justice.

Going back to the question asked, we need to tell the families to go back and ask for the response. If they do not get an appropriate response, there is an escalation and complaints pathway. We need to do better. We need to look at those and channel them through single point of access.

We now have health regions. Part of Sláintecare was the move from siloed care groups, where people had to navigate between pillars, into a more integrated health area. For the past two years we have had the regional executive officers, who have total oversight of the integrated services. That is down to community level. Ms O'Neill and her integrated health area colleagues are responsible not just for one care group like CAMHS or mental health, but for the delivery of integrated care close to home for the community. The single point of access and the process to improve it are being built on the integrated health area. We need those silos to be broken down.

I thank the witnesses for their responses. One of the most difficult things for any parent to hear is an eight-year-old child telling them they do not want to live. That is heartbreaking. It is against that background that they want the clinical escalation pathway that was mentioned. Is that available to everyone who presents with that issue?

We know we are doing reasonably well on urgent referrals and that 96% are responded to within three days.

If a child is mentioning suicide, that is urgent and requires escalation. It is not something we do not respond to.

I welcome the witnesses. I have spoken at length about the CAMHS scandal in both north and south Kerry. I have worked with many of the families over a number of years. Their stories are harrowing. We are talking about the most vulnerable children here. Many have multiple diagnoses. These children's families urgently need services. They need respite. Many families have not received respite for six or seven months, as I have mentioned here previously. Families are telling me that they are not receiving the services they require.

I received an email about two weeks ago. This person said they were emailing me out of desperation, asking me to organise a meeting with the Minister of State, Deputy Mary Butler, who was in Kerry on the day the email was sent and the following day. In fairness to the Minister of State, she has agreed to meet the family. The sender urgently requested a meeting with her as a last resort in keeping the family together. She says they have been through the most challenging and horrific time in trying to get help with their son. They have spent the past year in meetings trying to get respite and help with him. She says the resistance that has come their way would break anyone down. The facts and information and the struggles of this family are all there in the email to go through. It does not make for pleasant reading.

The sender says the family has exhausted all avenues and that they are pleading for help. She says that, as a family, they cannot sustain the pressure and mental position they find themselves in. They feel they will be left with no option but to hand their son over to the HSE as they can no longer go on without the help they need. She says they also feel they will be left with no choice but to go public about their situation and that the damage caused to their son in CAMHS has affected him and the family so much that the respite centre that was giving them respite is now refusing to provide any further respite due to the child being so challenging. Her son is severely autistic, has ADHD and a learning disability, and is a type-A diabetic. The family can no longer sustain this amount of care without the help they need to keep their son with them. They are exhausted. All of this has taken a severe toll on their mental health, including that of the family's 11-year-old daughter. This person says the family are not living but barely existing and that, if something is not done to help them now, the outlook is bleak. The sender then begs me for urgent help and gives her name, that of her son and their address, although I know the family anyway.

There are other families like that in Kerry. I feel hopeless when they come to me because their cases are not being addressed. How many children in Kerry are waiting for respite and services today? How long have they been waiting? How many beds are required to give the level of respite these children need and deserve? How long will it take to put these beds in place?

These families and their children are not getting services, including respite services. They believe they are forgotten. They are hitting a block wall. I have been in some of their homes and I have witnessed at first hand their extremely difficult situations. This has been outlined by colleagues of mine. This is 24-7 every week of the year, every year, until they get the services and respite they require. They are begging for our help. I am begging the HSE and the Department of Health to help these families to cope and to improve their children's quality of life and their own. We have to do more. As public representatives, we have no choice but to keep raising this issue and hammering it home. We have been doing it for years. It needs to improve quickly.

I am very familiar with the services in Kerry, particularly the respite services. I do not have the specific figure as to how many children are waiting for respite in Kerry but I can certainly provide it for the Deputy. While we cannot comment on a particular case, I am aware of the situation. There are many alternative forms of respite, including in-home support and in-reach into the home for home care. However, families tell us time and time again that they need overnight or weekend respite in order to cope and to support the child with additional and complex needs.

With regard to the funding we have received this year from a disability perspective, with our estates colleagues in Kerry and right across Cork, we are actively looking for additional houses that we can buy, staff and register with HIQA as respite houses for children and adults. There are two houses in Kerry. With regard to the number of beds and bed nights, there is actually very little to support those types of complex needs. A lot has been done in terms of respite services and working with the section 38 and section 39 organisations to provide such services. We are also going to alternative providers and looking at alternative pathways for respite. However, what the families are telling us time and time again is that they need overnight respite so we are looking to increase provision in that area. We have got additional funding through the office of the Minister of State with responsibility for disabilities and the Department of children to fund additional houses. We will move forward.

With regard to specific cases, we actively try to support families. Somebody is working on the particular case the Deputy has mentioned, trying to support that particular family.

I thank the witnesses for their presentations and for the work they are doing. We were talking about the shortage of people in key areas. Have the Department and the HSE engaged with the psychiatry institute on a training programme aimed at people who are suitably qualified to work in this whole area? We have employed a huge number of additional consultants in a lot of areas across the healthcare sector over the last ten years but we do not seem to have done this in a structured way within psychiatric services. What is the total number of qualified psychiatrists working in the HSE, whether working in adult psychiatry or dealing with young people? What level of engagement has occurred as regards putting in place a plan for the future? That is what this is all about. Is there a clear plan for the next five years to deal with the staffing challenges? It is not just about consultants. It is also about nursing staff, social workers and a whole lot of other areas. Is there a clear plan for training? Is there clear co-ordination with other Departments on this whole area?

I will take those questions. With regard to where the Department of Health is, we have a strategic workforce planning focus. Speaking to the Deputy's point, it is really important not just for now, but for the future, that we have a pipeline of the appropriate range of health and social care professionals to replace staff as they retire and to expand our services.

In relation to medical places, because our consultants start as trainee doctors, the Department has increased the number of training places for trainee doctors to start in the profession and within that, there are pathways.

What increase has occurred? For instance, they increased dramatically the number of people who are in GP training because they saw the challenge. They responded to that challenge and they now have a lot of people in training compared with ten years ago. I am not seeing any evidence of that in relation to psychiatry.

We will come back to the Deputy on that. As we expand our national clinical programmes in consultation with and led by our clinical colleagues, they identify through those programmes that we will be needing specialists in areas, whether it be eating disorders, addiction or early intervention psychosis. That informs workforce planning within the HSE and, in turn, informs how we do strategic workforce planning in the Department. Sometimes the clinical development allows us, and informs the requirement for, additional staff.

Ms McArdle might come back to me about the training programme expansion that has occurred and what is planned over the next five years.

I will do.

The second issue I want to touch on is the computerisation. For instance, something I do not understand in relation to what happened in south Kerry was prescribing. I presume pharmacists would have been the people dispensing but there does not appear to have been any checks and balances. What is the timescale for computerisation?

Is computerisation to be co-ordinated to make sure that it fits in with what the GPs and the pharmacists currently have? For instance, I raised this question of computerisation last week in relation to maternity hospitals and co-ordination with the new national children's hospital and it turns out there will be two different systems. I wonder what level of co-ordination there will be in relation to this computerised system and in relation to prescribing and making sure that there are appropriate checks and balances in place.

I will let Mr. Kelly in.

In terms of the electronic health record that is being rolled out, it is being rolled out with e-prescribing functions. There will be checks and balances in that.

As part of e-prescribing, we build a national formulary so there would be flags that come in place, because sometimes things are prescribed off-licence that you will be able to check and audit. In terms of the roll-out of that programme and the first regions going live, the mid-west is going live in July of this year and then subsequent regions all the way up until August of next year.

What of co-ordinating it with the other services, such as GPs?

This is part of the wider health service programme. I suppose it is a different programme. It is a different electronic health record to some of the systems, for example, that GPs and others are using. In terms of the wider developments that are going on around an integrated healthcare record and a care record that would share that information around the medication, etc., that is being developed by the HSE as well.

Will GPs be able to connect into it?

If they are given access, they would be able to. What will happen when a young person is prescribed and put on medication is that a letter will go out from the system directly to the GP informing them of that.

At this point in time as well, we are getting all the CAMHS teams directly on Healthlink, which is where the GPs directly refer into the CAMHS services themselves. There will be a much more improved system in terms of that communication and correspondence between them.

What of the timescale? They set out already that there were 252,000 attendances in CAMHS last year. That is 4,800 per week, which is a huge number of attendances.

It is.

In relation to setting up the computer system for all of this, what kind of timescale are we talking about before we will have a comprehensive service? For instance, we already introduced it in relation to maternity services for four hospitals seven years ago and we are still stuck where only a total of six of the 19 maternity hospitals are computerised. I wonder whether we are going to be in the same position in seven years' time where part of it is computerised in some areas and in other areas there will not be any computerisation at all.

Following on from the business case that we developed for CAMHS in order to get an electronic health record, the programme has since expanded into a so-called "community care record", which will be going across all community services. It will be across primary care, CAMHS services and palliative care.

The timeframe for the roll-out is that it will be rolled out region by region across all those services at that particular point in time. The timeframe is between the first area going live in July of this year and the last area of that implementation starting in August of 2027 and finishing by the end of next year.

Is Mr. Kelly talking about rolling it out over a 12-month to 18-month time period?

Yes.

Over the entire country?

Yes, for the entire country, apart from HSE Dublin and north east, which is looking at the new national electronic health record.

I thank Mr. Kelly.

I thank the Chair and thank everybody for coming here today. At the start, I pay tribute to the team in Kerry in particular. Ms O'Neill and the team there are always very responsive to any queries I may have.

I asked for a meeting with Ms McArdle last year about the delivery of a minor injuries unit, which we are still waiting on in Kerry. They have a couple of them in Cork already. We will be talking again about that. Ms McArdle is not here to answer questions about that but one in the north Kerry area will take the pressure off the emergency department, ED.

I am not going to go into the CAMHS situation and prescribing practices. On the compensation scheme, I could never understand why, where apologies have already been given by the HSE, people who are outside of the Maskey report parameters from 2016 to 2021 in the south Kerry area - if your treatment began in 2015 or 2014 or continued into 2022 in south Kerry or if you were in north Kerry - could not be included in that scheme where the HSE has already apologised. I understand that is to be widened out now. Why has it taken so long for families, delaying them further? Although they were victims clearly of what was reported by Dr. Colette Halpin and in Maskey, why were they still excluded and not given the facilities to pay for these very expensive medical reports, which the HSE will be paying for anyway because it has admitted liability?

The compensation scheme that was developed in relation to the Maskey report was very specific to the number of young people who were identified through that report. The State Claims Agency worked with other stakeholders but it was very much located and related to that report.

The Minister of State, Deputy Butler, has been clear that the compensation scheme is to be extended for this particular group, but it is on an evidence base. The production of the look-back report was the catalyst for expansion because that identifies where harm or where the risk of harm was and the numbers of people so far.