We have received apologies from Senator Nicole Ryan who is on maternity leave.

I remind members of the constitutional requirement that they must be 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 when he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any members participating via Microsoft Teams that, prior to making a contribution to the meeting, they confirm that they are on the grounds of the Leinster House complex.

The minutes of the meeting of 1 July have been circulated. Are they agreed? Agreed.

Today we will consider how hospital emergency departments respond to patients presenting with mental health issues. Unfortunately, such presentations are an all too common feature of our health services, with EDs becoming, in some cases, a default option for people in acute distress. Presentations to EDs involving self-harm and suicidal ideation are on the rise due to a lack of available alternatives, especially out of hours. For most people in crisis, emergency departments are not an appropriate environment for care. They are extremely busy and, as medicalised settings, they are the opposite of the calm, therapeutic environment people need. Not every hospital has a dedicated consultation room for mental health assessments. The failure to fund community-based services and early intervention supports is compounding that problem and placing enormous additional pressure on acute services. All too often, when people have taken the positive step of seeking help, they are effectively having doors closed on them despite all the talk of a "no wrong door" policy. This is not the fault of the overstretched healthcare workers but a failing on the part of the State. Until we see a real commitment of resources and an end to the stranglehold of the recruitment caps, we will not see the level of change that is needed.

I am looking forward to today's discussion on emergency departments, mental health presentations and how best the issue can be addressed. To assist the committee with this matter I welcome the president of the College of Psychiatrists of Ireland, Dr. Lorcan Martin, who is accompanied by colleagues, and the CEO of Mental Health Reform, Ms Helen Gillespie-Brown, who is also accompanied by colleagues.

I will read a note on privilege. 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 a 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 they comply with any such direction.

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

I invite the witnesses to make their opening remarks.

I thank the Cathaoirleach, Deputies and Senators for the invitation to discuss the response of emergency departments to patients presenting with mental health issues. We welcome the focus on this important area of mental healthcare.

I am a consultant specialist in general adult psychiatry. Accompanying me and representing the college are Dr. Karen O'Connor, consultant psychiatrist in adult psychiatry, Professor Siobhán MacHale, college vice president and consultant specialist in liaison psychiatry, and Dr. Henry Roberts, senior registrar in general adult psychiatry and chair of the college's training committee.

For perspective, the College of Psychiatrists of Ireland is the sole accredited training, education and professional body for psychiatry in Ireland. It represents over 1,500 psychiatrists, both specialists and trainees, across the country. The mission of the college is to promote excellence in the practice of psychiatry in all its components, namely, training for doctors to become specialists in psychiatry, lifelong continuous professional education and advocacy for evidence-based standards of care in mental health services, in order to achieve a fit-for-purpose contemporary service for Irish people. Although the college is not directly involved in service provision, the vast majority of its membership are front-line psychiatrists with cumulative millennia of training and experience. We are happy to provide advice, leadership and expertise.

Before we discuss some of the issues and suggest possible solutions, there are a couple of points to address. First, we should draw the distinction between people with mental illness and those experiencing solely psychological distress, however severe that might be. Both may present to an emergency department in crisis. Those with mental illness are the group with whom psychiatrists are concerned. We may be in a position to offer assessment and develop formulations for the latter group, but the solutions are generally outside the brief of psychiatry. Second, we can all agree a typical emergency department setting is no place for someone experiencing an acute mental health difficulty. Aside from the distress, they may be suffering from serious psychiatric symptoms. They may be a child or an older, possibly confused, person. They may have intellectual disability or significant neurodivergence. Conversely, it is not reasonable that people in a medical or surgical crisis should be further distressed by someone who is acutely disturbed.

Why does someone go to an emergency department with a mental health crisis? It is almost always a last resort.

It is because they are unable to or, indeed, unaware of how to access a timely and appropriate alternative. This is important to remember when we come to discuss how such difficulties may be ameliorated. However, we must remember that sometimes it is in order for someone to attend an emergency department. They may have experienced injury, self-inflicted or otherwise, in addition to their mental health difficulty. They may have a medical condition along with or contributing to their mental health problem. Furthermore, what may appear to be a mental health condition may actually be confusion or delirium caused by an underlying physical condition, even something as simple as a urinary tract infection. This is especially common in older people. In such cases, it is important that ED facilities reflect both medical and mental health needs in a sensitive and pragmatic way. In many cases, there is no access to a private consultation room for mental health assessment. Indeed, the Mental Health Commission report of 2025 highlights this inconsistency. It is quite simply neither appropriate nor possible to conduct a comprehensive assessment with the privacy afforded by a cubicle curtain. Furthermore, assessment areas must also be safe for both staff and patients.

Clearly, the best way to reduce mental health presentations to emergency departments is to provide alternatives. To use a cliché, we do not believe in re-inventing the wheel. There also are many examples of excellent practice and initiatives already in place. I, myself, lead a well-resourced and trained community mental health team which is in a position to offer rapid appointments to those in crisis, obviating the need to attend an ED but also a speedy response to those who require follow-up after an ED attendance. Dr. O’Connor leads the national clinical programme for early intervention in psychosis and a crisis intervention team, both of which contribute to reducing emergency department attendance. Professor MacHale leads a well-established and highly-effective liaison service in one of Dublin’s major hospitals. Clearly, there are examples of good practice and national policies which, if implemented fully, are fit for purpose.

At this point, we would like to acknowledge the continued commitment of the Minister of State, Deputy Mary Butler, to developing mental services and her engagement with stakeholders. However, she can only do so much unless adequately resourced and the percentage of the health budget allocated to mental health remains approximately half of what is needed.

While we are here to discuss the college's position and the role of psychiatry, we must first acknowledge that increased presentations of people with mental health difficulties in EDs is a much wider societal issue. Housing and homelessness, substance misuse, loneliness, lack of other community services and supports, poverty and many other factors contribute. They need to be addressed through other avenues.

I would like to highlight a number of points more specifically related to psychiatry. Of course, we are happy to expand on these and on any other questions members may have. First, without a doubt, an effective and properly resourced community mental health team is the backbone for the delivery of psychiatric services. Since 1984, Ireland has led the way in this regard. However, we now find ourselves with teams that are either inadequately staffed, lacking vital team members or staffed with temporary staff with a high turnover, which prevents the continuity of quality care. Whole-time equivalent ceilings, and pay and numbers policies, have left teams unable to do their job to the best of their ability.

Mental health care delivery is by people for people. We need to move away from numbers and spreadsheets, and focus on the patient. Teams without a full complement of clinicians will, inevitably, lead to longer waiting lists. As a consequence, patients become more unwell and are far more likely to resort to the emergency department for help.

The main focus of a psychiatrist’s remit is the diagnosis and management of mental illnesses such as schizophrenia, bipolar disorder, moderate to severe depression and severe anxiety disorders. In reality, we also often encounter people whose primary difficulties are owed to personality problems or personality disorders. A significant portion of those presenting to the emergency department in crisis out of hours with significant psychological distress and-or self-harm will have evidence of a personality disorder without necessarily having a major mental illness like those previously mentioned. These patients are frequently underserved by community services owing to a lack of psychotherapeutic treatments, which have been proven to significantly improve their lives. This leads to the so-called "revolving door" repeated presentations. If all community teams throughout the country had adequate resourcing to provide these treatments, it would markedly reduce the number of attendances at ED.

Historically, many people presenting to the emergency department were just admitted to a psychiatric bed. We have come a long way from having tens of thousands of psychiatric inpatients in this country. However, we must accept that inpatient beds will always be a necessary part of a well-functioning mental health service to treat those who are most ill.

We now must ask if we have reduced those numbers too much. The overall population continues to increase, there are great numbers of older persons requiring admission and there are increasing difficulties with substance-related psychoses. Furthermore, the demographics of particular areas of the country will mean that different services will have different needs. We should not assume one size fits all. We need to look at how inpatient beds are distributed across the country but also an efficient bed management system such that this important resource is utilised in a streamlined way.

Members may have noticed that I have not raised the issue of child and adolescent mental health services, CAMHS. This not because there are no difficulties. Lack of access to inpatient beds, and specialist community services, irregularity in the management of 16- and 17-year-olds, and out-of-hours assessment by non-CAMHS specialists remain. These issues have been addressed in other contexts and our CAMHS colleagues would be happy to speak to these issues if the committee would like further information.

Earlier I mentioned not re-inventing the wheel. The national clinical programmes and models of care have demonstrated clear efficacy but they must be expanded and resourced so that the whole population can avail of them. Crisis intervention teams provide people with a clear alternative pathway for help instead of going to the emergency department. The development of these services, as well as suicide crisis assessment nurses and other specialist nursing roles, need to be greatly expanded. However, it is essential that we do not forget the core clinical teams in the community. It would also be remiss of us not to mention the importance of training of the psychiatrists of the future. They are fundamental to service provision. It is vital that, whatever developments occur, their clinical training needs continue to be met in order to meet the requirement for skilled specialist doctors, as population needs increase.

Mental health crises, especially those presenting to emergency departments, are nuanced and complex. They require an holistic approach. While psychiatric services play an essential role supporting these people, it is also necessary to acknowledge that a broader societal change must occur. Timely access to support services, as well as ensuring that the basic needs of all people are met, are essential both at a societal and governmental level.

I thank the Chairperson and members for their time today, and consideration of our views on what is a complex and multifaceted issue. The college remains committed to advocating for excellence in psychiatric care and engaging with relevant stakeholders. We are happy to answer any questions and provide any further information members require.

I thank the Cathaoirleach and committee members for the invitation to appear before them today. I am the CEO of Mental Health Reform. I am joined by Dr. Louise Rooney, policy and research manager, and Ms Lisa-Marie O'Malley, policy and advocacy co-ordinator.

Mental Health Reform is Ireland’s leading national coalition on mental health. We have over 80 member organisations working for progressive reform of mental health services and supports in Ireland. We welcome the opportunity to contribute to this discussion on how hospital emergency departments respond to people presenting with mental health difficulties.

For many people in Ireland, the emergency department has become the default point of access for mental health crisis care, even though it is often the least appropriate setting in which that care can be delivered. The scale of reliance on EDs is significant. An estimated 51,000 first contacts with mental health services in Ireland take place through emergency departments and acute hospital wards. The National Self-Harm Registry recorded the following: there were 12,621 self-harm presentations in 2024; one in six was a repeat presentation, which indicates that many people leave hospital without their underlying needs being addressed; and the typical age of onset for self-harm is between ten and 14, which underlines the importance of early intervention.

Many people experiencing suicidal ideation, severe anxiety, psychosis, trauma-related distress or self-harm have no alternative but to attend an emergency department. This is not because it is the right clinical setting. It is because community crisis services remain inconsistent, out-of-hours supports are limited and urgent psychological care is often unavailable. Long-term solutions must prioritise care outside the ED, a need repeatedly recognised across the political spectrum and by the wider public, such as the calls made through the Adam’s Protocols campaign.

There are several fundamental issues with the current model. First, emergency departments are not therapeutic environments for people in mental health crisis. They are often crowded, noisy and overstimulating, designed primarily for physical illness.

For someone who is suicidal or acutely distressed, these environments can increase fear and anxiety. Long waits, limited privacy and repeated retelling of traumatic experiences can leave people feeling more vulnerable rather than supported. Mental health crises can occur at any time, yet many services still operate largely within office hours. The national self-harm registry found that 44% of self-harm presentations occur between 6 p.m. and 2 a.m., when community alternatives are least available. This also means An Garda Síochána is often required to respond to mental health emergencies where no crime has occurred. This places an unfair burden on gardaí and can be deeply distressing and stigmatising for the person in crisis, whose first interaction with the State should, wherever possible, be through healthcare rather than policing. Mental Health Reform welcomes the positive outcomes of the community access support team pilot in Limerick and hopes it will be expanded nationally following evaluation.

Access to specialist mental health assessment in emergency departments remains inconsistent, particularly out of hours. Liaison psychiatry services are essential, yet people still experience delays and fragmented care. Although Sharing the Vision recognised this need, the gap between policy and practice remains significant. Our members in the voluntary and community mental health sector provide a range of vital services to people experiencing crisis including helplines, talk therapies and solace cafes. Demand for voluntary and community sector crisis supports illustrates unmet need, with nearly 100,000 contacts to just one of many national 24-7 crisis helplines in 2024. This highlights both the level of distress and the importance of integrated responses between the statutory sector and the voluntary and community sector.

Continuity of care after discharge remains problematic. Many people leave emergency departments without timely follow-up or a clear care plan. In 2024, 26% of people who presented with self-harm to the emergency department without a referral were discharged home without any follow-up care arrangement being made or documented. This excludes those who leave before assessment due to long waits. Families are often left to co-ordinate care themselves, and many people experience repeated crises as underlying needs remain unmet. Good crisis care should allow people to access support before reaching breaking point. It should include 24-7 community-based crisis assessment, nationally available crisis resolution and home treatment teams, and alternatives such as solace cafes and community stabilisation services.

Where emergency care is required, people should receive rapid specialist assessment in a setting that protects privacy, dignity and compassion, followed by timely community follow-up. On that basis, Mental Health Reform asks the committee to prioritise six actions. First, it should accelerate the national rollout of 24-7 crisis resolution and home treatment teams to ensure equitable access regardless of geographic location. This would enable more people to receive intensive support at home, reduce hospital admissions and support earlier intervention during crisis. Second, it should ensure that every acute hospital has adequately staffed liaison psychiatry services, including full out-of-hours cover. Emergency departments should, at a minimum, meet psychiatric liaison accreditation network standards and provide dedicated mental health spaces in the short term, while longer term alternatives are developed. This would improve safety, dignity and quality of care, and reduce repeat presentations. Third, it should further develop and expand community-based alternatives to emergency departments, including solace cafes and crisis assessment and stabilisation services. This would provide earlier, more holistic support options and reduce pressure on emergency departments. Fourth, it should ensure timely post-discharge follow-up within 48 to 72 hours, supported by clear accountability structures, alongside continued investment in community mental health services and urgent psychological supports. This would enhance continuity of care, reduce relapse risk and prevent avoidable reattendance or readmission. Fifth, it should strengthen national data collection on mental health presentations, waiting times, repeat attendances, follow-up and outcomes. This would improve accountability and service planning, and ensure services are grounded in real-world need. Finally, it is essential to ensure that people with lived experience, along with family members, are directly involved in the design and evaluation of crisis services. This would ensure services are truly responsive and person-centred.

I acknowledge the professionalism, skill and compassion of staff working across emergency departments and mental health services. Every day, they deliver vital care under considerable pressure within a system that is under-resourced. Their ongoing commitment to patient care is commendable. I also acknowledge the continued commitment of the Minister of State, Deputy Butler, and the progress made in recent years. The €15 million allocated in budget 2026 for crisis supports including crisis resolution services; solace cafes, good examples of which are successfully operating; specialist emergency department mental health nurses; and suicide crisis assessment nurses is welcome. With budget 2027 approaching, we urge the Government to prioritise sustained investment in mental health services so people can access timely, compassionate care in the right place at the right time. We need a crisis care system that treats mental health emergencies with the same urgency and compassion as physical health emergencies and recognises that every emergency department presentation is a person at a moment of profound vulnerability. We look forward to the discussion and thank committee members for their time.

I thank the witnesses. I now invite members to discuss matters with witnesses. Each member will get nine minutes to put questions to the witnesses. Members will decide who can take the questions. We will take a break in about an hour. We will start with the agreed rota we follow.

I recognise that the Government's record investment in mental health services of €1.8 billion, which is the highest ever investment, is still not enough. We need to reach an investment of at least 10% of our health budget in mental health services. We are running at about 5.7%. We are playing catch-up because of our lack of capacity and our growth in population. I pay tribute to the commitment of the Minister of State, Deputy Butler, to that. Notwithstanding that, we have very significant problems.

Sometimes it is easy to be in a committee here and have a sterile discussion where people present facts, figures and opinions often based on their own experience. I am going to give something from my experience as a GP. A very distressed young mother of two children, in difficult social circumstances, made a serious attempt on her own life. A search party was sent out and she was found by a local garda in the woods with a rope. She was brought to the emergency department. She was eventually seen after 12 hours by a junior doctor. I say that with no disrespect to the junior doctor. She was sent home after a phone consultation between the junior doctor and the consultant psychiatrist. She received a five-minute phone call from a nurse each day for seven days until she was eventually assessed by a consultant psychiatrist. As her GP, in my view she was suffering from severe depression. Her circumstances contributed to that but she deserved to be seen by a consultant psychiatrist for assessment when she was brought to the emergency room. That is the reality on the ground in terms of access to mental health services around the country. The witnesses are quite right to point out that there are some excellent examples, but there is an inconsistency right around the country.

Some of that comes down to capacity, but some of it comes down to culture. We need to recognise that. Yesterday, I received a response to a parliamentary question from HSE West and North West. I had asked for the number of referrals to CAMHS in that region in the last five years. It was unable to provide me with that data because it did not have any data about the people who were using the service or who needed to. It was unable to provide me with data on the diagnoses of adults referred to the mental health services in HSE West and North West. That is simply unbelievable in this day and age. What is more important, because it relates to an area of real contention, is that it was unable to provide me with any data regarding young people in CAMHS who were transitioning to adult mental health services. We know that is problematic. I will start there because these young people and other people with mental health issues end up in the emergency room because they cannot access services in a timely manner. Is it true that there is no data available on the need for mental health services and diagnosis?

It is not that there is no data. One of the difficulties is that we are largely without the information technology required to collect and collate that data, allowing us to forward it on.

Are diagnoses recorded?

Diagnoses are recorded every time somebody is seen.

If diagnoses are being recorded, where is that data kept?

That data is usually kept on the patient's chart. Depending on where you are, the ICT system may be more developed, in which case there may be a database, but unfortunately it is a lottery because, as we have been saying for years, we need ICT systems that operate across the board and electronic patient records. That simply has not happened.

In most organisations, audits are carried out regardless of whether you have information technology. This would show the number of people with enduring mental health issues, such as schizophrenia, bipolar disorder or whatever. There are simply no figures. I find that incredible. I do not know how we can plan a service if we do not know how many people need to use it.

On the issue of emergency rooms, over the last number of weeks, we have been talking about Sláintecare and access to consultant-delivered services. Is it a capacity issue that junior doctors do not have adequate access to specialists out of hours? That is not a criticism. I am just trying to understand. If an experienced GP sends someone in who is having an acute psychotic episode, one would expect that person would be seen by someone who is competent in that area. When I was a GP in training, it was an inadequate service for me to assess someone who was psychotic. That was a long time ago but that practice is still going on.

The initial assessment would usually be carried out by someone in a non-consultant grade but there would also be a consultant supervising that person. That consultant is available to that non-consultant doctor by telephone or in person, if necessary. There is access to a consultant at all times.

Is it a capacity issue? If this was an ideal world and we had enough consultant psychiatrists, would be we able to provide a different type of service and provide referrals to appropriate acute centres.

The Deputy has asked about "an ideal world" but the volume required would be very large.

May I come in on that? It is just because I work in the early intervention in psychosis programme. You really want that referral coming into an early intervention in psychosis team so that the person can be seen in the community and never has to go to the emergency department. The person would then be seen by a multidisciplinary team.

I accept that but that is not the case where I live and work.

I understand.

I accept that is the answer.

That is where we want to go.

In Roscommon and east Galway, we have an acute psychiatric unit in Roscommon, which is almost 30 miles away from the emergency room in Portiuncula hospital. There is no link-up. There are two different physical settings to provide that service. We have that disconnect. CAMHS exists in Roscommon but people in Portumna have to go to Roscommon to get it.

I thank the members for the very welcome tone of this discussion, which really underlines the challenges we are facing. As a liaison psychiatrist, I tend to use medical analogies. The situation is similar to sending every patient who is having a heart attack into the emergency department, which is important, while having no access to coronary care beds or cardiology services along with it. The question is then whether we need every single person with a chest pain to be seen by a cardiac consultant. In a similar way, does every single patient who presents with distress need to be seen by a consultant psychiatrist? How do we determine-----

I am not saying that. I was specific in what I said. I spoke about people being sent in because, in the estimation of a senior GP in the community, they had enduring mental health issues or psychosis or were deeply depressed and suicidal. There is no other service that does not get that access.

I come back to the lack of data. Most other services have the data. We know how many people presented with chest pain and had a heart attack, how many strokes there were and how many people presented because they were in a diabetic crisis. There is no data in our mental health services. I cannot believe that. I am shocked.

Data is key. When I chaired the national clinical programme for the management of self-harm, we introduced time for data collection within the nursing resource. That has been a key component in measuring the output of the self-harm programme, allowing us to improve and develop it.

I will ask one last question because I am running out of time. Do the witnesses believe we should have sectoral referral? There is no other specialty in medicine that has sectoral referral. If I see someone who has chest pain, I can send them to Tullamore or Galway.

I ask the witnesses for a very brief answer because Deputy Daly is out of time.

The reason for the sectoral geographical arrangement of the mental health services is because so much mental health service delivery happens in the community. Geographically, it would be extremely difficult to have your colleagues on a multidisciplinary team spread across three or four counties. That is the reason.

There is no choice.

I thank our guests for coming in today. It is less than six months since Sinn Féin proposed a motion in the Dáil on the provision of dedicated areas within accident and emergency departments for the provision of appropriate mental health interventions to those in crisis. I welcome the fact that the Government did not oppose the motion at the time, but not opposing a motion does not get us where we need to be as regards the delivery of mental health care, whether in the community or in an emergency department for those who have no option but to present there.

I take the point Dr. Martin made about differentiating between those who need psychiatric care and those who need psychological care in an accident and emergency department but I am firmly of the opinion that, without a dedicated space, even making that assessment is incredibly difficult for the patient, the person who is in crisis and those charged with determining that person's needs.

I will follow up on the issue of parliamentary questions and the data collected. I address this question to the College of Psychiatrists of Ireland. When I send in a parliamentary question that is then referred to the HSE, I will get a response detailing, for example, the number of children waiting on a CAMHS appointment in each area. Does the HSE ask psychiatrists for the number of referrals made as opposed to the number of referrals that are accepted? If ten referrals are made to CAMHS and five are not accepted, which number is reported?

I should say that I do not work in CAMHS, so I cannot answer that question directly. However, from an adult services perspective, we are asked for the number of referrals we get and we are also asked for the number of referred patients we see. We are asked for both.

Does the HSE ask psychiatrists to provide information on diagnoses for those in community settings, those receiving inpatient care or those anywhere else on the spectrum of mental health service provision?

No. We are not usually asked for that information, although we can provide that information if it is needed.

What I am trying to get at is that I believe that data is there. I believe a decision is being made not to collate it. There are different reasons for that. If we do not collate the data, we are never going to be able to assess the level of need and, therefore, will never be able to plan effectively to meet it. That is what I want today to be about. I do not want today to be only about focusing on the problems. We know what the problems are. It is fragmented.

It is not a marginal issue. It is a standing failure. It has very real consequences for people. Adam's protocols were mentioned earlier. Adam was a young man who lost his life to suicide after leaving an accident and emergency unit. I do not believe anybody on this committee or anybody in the Oireachtas wants to see that being repeated.

From the perspective of the College of Psychiatrists of Ireland, it was mentioned that the mental health budget is about half of where it needs to be. If budget 2027 provided every single euro that is needed, do we have enough mental health professionals to deliver the service?

I would say at the moment we do not. Teams are missing people. Some of that is due to budgetary constraints – pay and numbers and so on – but if we were to effectively double the mental health budget now we would then need to find the people to put into those jobs. The other important thing is we need to create an environment where people are working so that they will stay in those jobs. That is really important because one of the things I have noticed – just speaking for my own team – is that we have people working in the same team for 20 years. There is continuity of care and a level of experience. What we want is properly trained, well-experienced professionals filling out all the different parts of multidisciplinary teams. Whether they are community mental health teams, early intervention teams, liaison teams, CAMHS teams or whatever it is, they need to be properly staffed with the properly trained professionals.

The issue that is there is not primarily a recruitment one, as such. It is also a retention issue.

It is a bit of both. The mental health arena is difficult. It is particularly difficult for the patient but it can also be quite difficult for staff. Burn-out is not unheard of and people do not always stay. The vast majority of mental health professionals are very dedicated and give way more than they need to give because our focus has to be at all times on the patient and their family and carers.

It is important that is recognised by the committee as well. It is a difficult job and oftentimes it is done in difficult circumstances. The challenges our mental health services have are not the responsibility of those front-line workers who are doing their absolute best for the patient who is sitting in front of them.

From Dr. Martin's professional experience, if he were to highlight any specific area where he sees the greatest impact of the staffing and retention issue that exists, what would it be?

It would be very difficult to pick any one. Dr. O'Connor, Professor MacHale and Dr. Roberts might have their own opinions on this one. The core of community mental health teams are missing people but then so are many of the CAMHS teams. A number of the more specialist services, such as crisis intervention teams, are still missing people. Not every team has all the various disciplines they need. Professor MacHale has experience of the liaison team.

We very much welcome the focus on the emergency department through the model of care for liaison psychiatry and all the policy development supporting the need for appropriate care for patients in acute hospital settings, including the emergency department. In a lot of ways, that has allowed us to develop better resourced teams than we have in the community. From my experience working in the acute hospital emergency department, the challenges are for the community teams to be able to accept patients in a timely manner.

The other thing I would point out is very few crises happen over a couple of hours. Most crises develop over a few days or a few weeks. People are trying to access care at that time. To me, that is a pivotal component of the accessibility aspect of resourcing a service in a timely way in terms of things like early intervention. It is also the case that 70% of patients who come to the emergency department do not have a medical need to be there. We know, for example, a significant proportion of those patients are already attending community mental health teams but they do not have access to them to be seen over the preceding few days by a member of the team who is familiar with them for a range of reasons. To me, that is where the resource components are a key part.

I have one eye on the clock. I have a question to ask Mental Health Reform. In the opinion of the witnesses, for somebody who is presenting with a suicide or mental health crisis in general to an emergency department anywhere, whether it is a model 3 or a model 4 hospital, what should the first six hours look like for that person?

I will pass over to my policy manager, Dr. Rooney.

On the first six hours, ultimately what we are talking about is that the emergency department is the end of the pathway. The crisis begins way before.

The reason I am asking that is because I am firmly of the opinion that until our community services are fit for purpose and can meet people where they are in a timely manner, we are always going to have a need for an accident and emergency response. That is why I am focusing on the accident and emergency response.

Ideally, it would be to be triaged as quickly as possible. A key piece is being able to be somewhere in that environment that is appropriate – somewhere that is not clinical. The emergency department is so busy. It is loud.

It is bright and noisy. It is a very messy environment.

Even while people are waiting, there should be an environment where there is an element of psychological safety to that wait, which is conducive to the fact that they are in distress and not adding to the distress. It is about seeing somebody as quickly as possible who can address the needs they have within those first six hours.

From the work and the research the witnesses have done, are they of the opinion that the current set-up in emergency departments is not conducive to the most positive outcome for a patient?

Yes.

I just want to add that a dedicated mental health assessment room within hospitals will provide a more appropriate environment for assessments to take place. That is fundamental. Given that most of the key mental health inpatient units are co-located within an acute hospital network, people in distress can be assessed in clinically appropriate environments when they present for support.

I thank the witnesses for being here. I for one really welcome this debate because for too long people were very clumsy around the whole conversation about mental health. Somehow or other the mental health title weighs a bit heavy on me. We should find some other way to describe it because it almost suggests that anyone who presents with an emotional or psychological issue is somehow considered to be mental.

A few things stand out. I would be the first to acknowledge that we have come a considerable distance over the last ten years, but we have quite a road to travel. From listening to both statements, the greatest issue is the funding of the services. Dr. Martin mentioned that the budget is roughly about half what it should be, and the population is growing. There is a crisis when we do not acknowledge that more people will be presenting as a consequence of an increasing population, so we need to be prepared for that. If we do not do that, there is a failing in the system.

For a long time I worked as a volunteer within the services as a consequence of our own family tragedy going back to 2010. What alarmed me is that somewhere in the region of 550 to 600 people had lost their lives that year. I often thought that if a jumbo jet had crashed with a similar number of lives lost there would be a national day of mourning. People were sneaking away ending their lives and there was little by way of serious conversation being had about the need for us to do more. I am glad that we are having this conversation and that we have come this distance. Here is where I would like it to go. I was one of those advocating for a single point of access, let it be community access or direct access to clinical or psychological services within each hospital. We had the very sad tragedy in Galway where a young chap was sent to the accident and emergency unit to be assessed. Like so many more, he was emotionally demented and tormented and he just could not follow through with the wait in the accident and emergency unit; he left and the rest is history. For his family and anyone who has experienced that, it clearly is not good enough because, as I often reference, it is the last place a person would want to be.

People are referred there by a GP, but they know in their heart and soul that the only ones capable of fixing them are somewhere up there in a team. They do not want to be sitting alongside individuals with broken arms or legs. Those are easily managed pains compared with the pain they are experiencing, which is unbelievably difficult to manage. They are trying to get that help and manoeuvre through that process. We must get direct, signposted services, both for those who present to the accident and emergency department and at a community level with access to a clinical or psychological nurse. Continuing to lose people as a consequence of that delay is a disservice. I do not know what the views of the witnesses are in that regard.

If we ever have that model, I genuinely believe many people would be saved. Based on my years of volunteering, it is fundamentally true that a lot of people do not need clinical intervention; they need to be understood. They are in an emotional crisis or struggling with anxiety. Often, all they need is reassurance. They can go on to have a normal life. Whether it relates to financial, domestic or sexual issues, or people struggling with intimidation or abuse, historical abuse or otherwise, a lot of people will survive their crises without medical support. That is my belief.

We need to take the task ahead seriously and properly fund it, and we need to take seriously what most observers suggest, that is, easy access and timely intervention. I attest to the fact that it is not easy, but one thing that is for sure is that anyone who has had a crisis in their life will not come out praising the services if they have had to wait for prolonged periods in the accident and emergency department. Often, they praise the support they received from a trained councillor, or whatever the case may be. Are we close to having the kind of model that I am speaking about where there is easy access and a kind of one-stop-shop rather than being thrown from pillar to post and being referred to the general hospital, such as University Hospital Galway, UHG?

First, I offer my condolences on the Deputy’s personal tragedy a number of years ago. I will pass over to Dr. Roberts to talk a bit about what it is like on the ground in casualty and why people are experiencing these difficulties. I will then pass over to Dr. O’Connor to talk about some of the options that may be available in the context of the crisis one-stop-shop the Deputy is talking about.

When we are talking about an on-call situation, there is often one psychiatry trainee in the hospital and he or she is covering the collocated psychiatric inpatient unit, which may have between 20 and 50 beds, the emergency department and, technically speaking, all of the medical wards in the event of any psychiatric issues overnight. Often, that trainee is responsible for approximately 800 patients on a large hospital campus.

I agree with the Deputy that the wait people have to go through in the accident and emergency department is unacceptable. I was only thinking about this last night. I will use the example where I start my night shift at 9 p.m., which is often the case. Let us say that I receive two patients at the handover at 8 p.m. While they are referred at 8 p.m., they have been waiting in the accident and emergency department since 2 p.m. to see the emergency doctors. I then have to go to the psychiatric unit for involuntary admissions that need to be done. There is a lot of paperwork to complete in that regard. It might be 12 midnight before I get down to the accident and emergency department. Another doctor then refers another patient to me. I see one of those patients, but there is a medical emergency in the psychiatric unit and I have to go back to deal with that. Next thing, we are up to 7 a.m. It is backwards and forwards. It is challenging to try to balance the priorities.

Deputy Daly spoke about being assessed by a junior doctor. In order to get to a consultant level of experience, junior doctors must assess. While the word "junior" is used, the term "non-consultant hospital doctor" is probably bit more accurate. Junior doctors can have six or seven years of experience. They are experienced doctors. It varies.

The solution is staffing. We have to balance the needs of trainees to see a lot of different patients and presentations and learn how to take on risk and manage. That is part of our speciality. We also need more funding in accident and emergency departments, particularly when it comes to out-of-hours services where one doctor is covering an entire hospital campus.

I will speak about some of the alternatives that are on the ground at the moment. They are not everywhere, however, and need to be scaled up. I work in a crisis resolution team. Essentially, if a GP is concerned about someone, he or she can contact us and we can see that individual on the same day, the next day or within three days. The GP can tick different boxes in this regard. The referral is sent through Healthlink. It is an electronic referral. We will then get straight back onto the GP. That person will be seen by a multidisciplinary team. It is not just a doctor or a nurse; we have the full complement. We see people within the timeframe specified, carry out a specialist assessment and set out a care plan. We can see people at home, in the community or anywhere they want. Sometimes, we meet people in cafés and parks if that is where they are comfortable meeting. We try to home-treat in order to offer a genuine alternative to hospital admission. We see people every day, and sometimes twice a day. We also work with their families. There is data published based on five years of this type of work.

I thank Dr. O'Connor. We are over time.

Will I stop?

Yes.

I will send the Deputy the data.

We have to be strict on time. We try to ensure that every member gets nine minutes each and that we conclude at 12 p.m. because there is another committee meeting straight after us. Hopefully, we can pick this issue back up.

The next slot is mine. Reflecting on what we have heard this morning, particularly in the context of mental health presentations in emergency departments, there seem to be two key issues, namely, staffing and facilities. I noticed that there was an announcement from the Minister of State, Deputy Butler, this morning announcing ten specialist crisis nursing teams in emergency departments around the country. Certainly, they will go some way to help. I am sure they will be welcomed by the witnesses and others. There was no mention, however, of the facilities that needed to go with those teams. There is a lack of consultation rooms. It is clear an environment is needed that is not busy or chaotic and that does not have bright lights. There is a need for calmer facilities. It would be good to hear from the Minister of State today in response to that and to find out what will be done to improve facilities alongside the additional staffing she has announced.

My other concern is about the gaps between emergency care, care in the community and outpatient care. I will briefly set out a case. Recently, I met a constituent whose brother had died by suicide. This person presented to his GP with suicidal ideation and substance misuse. The GP recognised the risk and referred him urgently to the accident and emergency department, where he met a registrar who cared for him, discussed the situation with a family member and referred him to an outpatient service. He also saw a private consultant for an ADHD diagnosis. The consultant explicitly noted the suicidal ideation and depressive episodes in the clinical notes, which were brought to the HSE outpatient service. Despite the urgent referral and his consultant’s warning in the clinical notes provided, the outpatient service discharged him, stating that he did not meet the service criteria. This was done without a discharge plan or a letter to his GP. He received some information about a mental health charity that might be able to support him. Weeks after he was told that he did not meet the outpatient criteria, he died by suicide. The HSE confirmed to me that a category 1 incident review will not be conducted in this case because he was not under the care of the community mental health team. This case and others that we have heard raise concerns about the continuity of care in our mental health services and the integration of different services. Are the discharge criteria in acute and community settings in need of reform?

Obviously, we cannot comment on any one particular case but one of the big things in all of this is that mental health services are often geographically disparate. Someone might be seen in casualty in one area – in my case, it would be in Athlone – but seen in another area for their outpatient care and so forth. Communication is key. That is an important part. The problem in that regard is that, as it stands, we are relying on pen and paper and people doing things because we do not have the necessary electronic communications. While an electronic system will not solve everything by any manner or means - people still need to use it correctly - it will streamline things. For example, one of the difficulties is that something might be sent from an accident and emergency department but it might not get to the community mental health team for a couple of days.

Continuity of communication is vital so that we have all the information.

The most basic part of carrying out a psychiatric assessment is to have as much information as possible about the person, their family and their situation.

On discharge criteria, I cannot comment on any particular team. Generally, however, teams would discharge a person safely. They would have a safety plan in place, communicate with the GP and ensure the patient or family, or both, were agreeable to the discharge at the time. There would also be a plan in place should the individual need to get back into services quickly. That would be the standard for most mental health teams.

The point raised in this case was the lack of a referral back to the GP or continuity of care. The witness made a very good point about electronic records. It is a real case of why we need to see massive investment in services. It would pay off in the long term.

Mental Health Reform's opening statement called for timely post-discharge follow-up within 48 to 72 hours, supported by clear accountability structures. What would this look like in practice?

I am happy to jump in there. First, I thank the committee very much for having us here today.

We recently published our pre-budget submission. I mention that because every point raised so far, be it related to access, data or the workforce, came up in our consultations. One that arose consistently was on the continuity-of-care element that Ms Gillespie-Brown mentioned in terms of the statistic that 26% of people presenting with self-harm left without any discharge plan or follow-up documented. The Cathaoirleach is absolutely right that this is unacceptable from a continuity-of-care perspective. People with lived experience constantly say to us that they have experience of leaving emergency departments without any specific follow-up or plan. They may have received some documentation, but really nothing else to go on.

Obviously, we want to see wraparound support. This is where the link between the community and voluntary sector and the statutory services needs to be much stronger. The voluntary and community sector can ensure there is access and support. People with lived experience constantly talk about the supports they can get from the community and voluntary sector, but I suppose the link is missing. The community mental health teams that were referred to are also critical. Discharge and follow-up need to happen as quickly as possible because, sadly, people are waiting much too long for these or else have to see multiple people and retell their stories to them, which is very retraumatising. I am conscious of time because I am speaking very quickly.

In the same way that waiting lists are problematic, people have no active waiting supports. We did research with UCD a few years ago with doctors and nurses working in emergency departments and they spoke about the fact that they did not have the information to give people about community supports. It is a matter of the social-prescribing element. A person may well be leaving with a referral, but there are also community and voluntary sector services that can help while waiting. Having local knowledge and being able to pass it on means the family and the person do not have to navigate the sector. That was also called for by the Garda Síochána. It is important that everybody providing crisis support have somewhere to signpost and direct people.

In the opening statement, reference was made to Adam's Protocols and the campaign following the death of Adam by suicide. The campaign is calling for direct alternatives to emergency departments, similar to those developed in Canada, the UK and Australia, with separate units for mental health crises that operate 24 hours a day, seven days a week, and without a referral being required. Will the witness briefly tell the committee a little more about that and why it is important?

Absolutely. In terms of alternatives to crisis care, it comes back to the reality that people are in crisis. Other Deputies have spoken about it. Deputy Roche made a point about the very different pain people are experiencing and the need for a space that is trauma-informed and where it is not chaotic and there is not a lot happening. That is really what it comes down to in terms of what we are calling for and the need that exists. In an ideal world, we would have a separate space for people who are presenting only with mental health crises. As an alternative to that, a certain room or space within-----

Just on that, the committee received a briefing note from the HSE that states that only a small number of emergency departments do not currently have a dedicated mental health assessment room. Is that the experience on the ground?

I will respond to that. It is, in fact, the case. A component of the national clinical programme for self-harm assessment is ensuring that each of the emergency departments has such a space. There are spaces; the challenge relates to whether they are the right spaces. I work in Beaumont Hospital, where the emergency department in general is a very challenged space. Having a room that meets the psychiatric liaison accreditation network, PLAN, requirements referred to earlier in itself does not mean it is appropriate. Historically, patients used to be able to present to their local community psychiatry service. As we have evolved, a lot of the walk-in access has closed. In my area, for example, St. Ita's Hospital and St. Vincent’s Hospital, Fairview, have closed their walk-in access.

So, there is certainly still an issue with the facilities and the requirement to improve those. We can follow up with the Minister on this.

The witnesses are all very welcome. In both presentations, I suppose the main argument being made is that emergency departments have essentially become the default access point for mental health services. If that is the case, it points to failures and breakdowns outside hospitals. We all know that and we have dealt with all these issues in this committee for some time. Maybe some of the witnesses could talk about what immediate actions could be taken outside emergency departments? What are the core priorities we need to grapple with to prevent a situation in which emergency departments have become the default point of care, when we know they are not equipped to deal with what we are asking them to do? I want to give the witnesses the opportunity to address those main areas.

Many of the models that work are evidence-based. We know about them and they are in our policies. We are very confident about them. The challenge is scaling them up and having them across the country so there is not such variation. They include crisis resolution teams, early-intervention psychosis teams, suicide crisis assessment nurses, and the self-harm programme. At the moment, we have pockets of really good practice. What we need is a system in which people have ready access to the services in the community rather than having to present at an emergency department. We need less variation and these services need to be scaled up everywhere across the country.

One of the other difficulties is that, where these services exist, people do not always know about them. We have a job to do in informing not just the public but also other medical practitioners that the services are on offer and how easy they are to access. As Dr. O'Connor said, they are not everywhere and need to be scaled up and made available across the board. One of the difficulties is that the casualty department is still the default. People say that if they are not feeling well, they should go to the accident and emergency department. However, if they talk to a GP, the GP might say they could be seen the same day by a crisis intervention team. We have a job to do in terms of communicating that.

How do we do that? One hopes that if someone goes to their GP, that person would be given the right pathway. If the required services are available in their area, although they are not available in every area, one would hope the person would be sent to them. Is it the case that, when there is a crisis, patients themselves believe the only option is to go to an emergency department? How do we break that?

I started a crisis resolution team ten years ago. I remember we spent perhaps a year or two explaining to people that we were a genuine alternative. People had not experienced it before, so they were much more comfortable going straight to the emergency department because they knew they would see somebody there. There is PR and communications work to be done so people develop confidence in the new ways of doing things.

I support the conversation we had on crisis resolution teams. They reduce emergency department presentations and hospital admissions. They provide intensive supports at home, operate out of hours and can integrate with voluntary and community services. We know that crisis resolution teams, when they operate, are extremely successful. We see the evidence. International evidence demonstrates that crisis resolution teams provide safe and effective alternatives to hospital admission for many people experiencing acute mental health crises.

I just want to pick up on where I had spoken before with Deputy Clarke about this pathway piece. Everything we are talking about right now is very clinical. Crisis really begins way before then. We are talking about prevention and early intervention. If we are really to address it, we need to look at it before distress is even felt. Mental health-----

That is the point I was making. If someone ends up in an emergency department, it means that all the other options have failed, a person has not reached out or the service was not available to them much earlier.

It is about mental health promotion programmes in schools, making sure our children are resilient and that they know how to seek help and how to recognise mental health issues as they arise. Then it is being able to identify early intervention programmes that are there from that mental health promotion that they have been taught. A lot of these things are already in the community but we also need really dedicated and targeted funding into our community interventions because they are key to making sure people do not end up at the end of the pathway. The end of the pathway is where we do not want people to end up. There are so many things we can do before that. Before somebody needs to be in contact with a SCAN nurse, the hope is that they can access community and voluntary supports but we need ring-fenced funding to expand those supports.

One of the statistics in the information we received for today's meeting was that 44% of presentations for self-harm happen between 6 p.m. and 2 a.m. Again, I imagine part of the problem here is out-of-hours services. If they are not available, the only option might be to go to an emergency department. How equipped are we in lots of areas of the health service? I know there is a big discussion now about a seven-day health service in hospitals and so on, but in the community especially, it is designed from a 9 a.m. to a 5 p.m. or 6 p.m. set-up. For mental health and probably for lots of other areas this is limited. If we go to a dietician, we can get an appointment and go within those working hours but mental health is different. We have to be able to react and be there for people when they need it. How important is that? Are the crisis resolution teams and home treatment teams currently set up for a 24-7 service? What more can be done to make sure we have more of that?

Most of them are operating extended hours; not necessarily 24-7 but certainly extended hours over seven.

What is it extended up to?

They vary up to 9 p.m. or 10 p.m. The other thing worth mentioning which they are integrated with are the solace cafés. The teams are set up together. They are very integrated with each other. A number of our teams are also integrated with addiction services. They are on our team and we work together.

However, despite those teams being there - and I accept they operate up to those extended hours, which is great - what I am asking is if overall, Statewide, we are equipped to deal with presentations outside of what are normal working hours.

Yes. It is definitely something we need to continue to scale up. If someone self-harms and needs medical attention, he or she will have to go to the emergency department. There is a certain proportion of that that will continue. That happens out of hours a bit more for other reasons.

On what Dr. O'Connor was saying about patients presenting to their GP and instead of going to the accident and emergency department going to the crisis intervention service, I have often encountered patients in the accident and emergency department who said they tried to contact their GP and could not get an appointment for two weeks. That is outside the immediate scope of this discussion but it is very much a part of this that we do not have enough GPs. If we had more ready access to GP, patients could be diverted into the appropriate-----

I do not want to cast aspersions on GPs because they are very busy and do great work. Obviously, GP services have to triage patients as well. However, part of this if somebody phones and presents with a mental health issue is what level of priority it is given in terms of an appointment. That may be an issue as well. The Solace Cafés were referenced and they also do great work. Do any of the witnesses want to expand on those?

The solace café is delivered in the community by community organisations but in collaboration with the HSE. We have one in Cork and our team works with the café. If the staff ever has someone who is attending the café who it would like the crisis team to see, we do direct referrals. They just pick up the phone to us.

Ms O'Malley wanted to come in.

I just wanted to come in to say the cafés do great work in terms of out-of-hours support. Dr. O'Connor already covered it. The challenge in scaling up in that there needs to be a lot more of them. Right now in general they are working by appointment only, which is obviously not ideal for crisis supports. That is something we would very much be hoping can change going forward. The cafés are still in early stages, but it is great to see that support for them within the budget.

Very good. I thank the witnesses for attending today. It was very helpful.

I suggest we take a quick break and resume in five minutes. Is that agreed? Agreed.

I thank the witnesses for their presentations and for the work they are doing in this area. I know this is very challenging, and there is a different challenge each day in dealing with their patients.

Referring to the paragraph Dr. Martin discussed, going back years ago, we had thousands of psychiatric beds and we closed down a substantial proportion of them. We now have an increase in population of over 40%, yet we have not increased the number of inpatient beds in real terms. Does Dr. Martin have any idea of the current numbers we are talking about? With the increase in population over the past 20 years, has there been any increase in the number of inpatient beds?

There has been an increase in the number of inpatient beds overall, give or take a couple either way. However, we are seeing that, by and large, psychiatric units are running close to 100% occupancy, which is one of the difficulties. We also do not have a lot of flexibility within the system. For example, if someone needs an urgent admission, we often wind up having to go to other hospitals.

One of the difficulties is that when the bed numbers were decided upon, the population was not only lower but its demographic was also different. We are now seeing a larger population presenting with larger, more complex problems. Very often, it might be psychosis but it might also be co-morbid substance misuse and so on. We are also seeing a change in the demographic of the population as regards people coming from other countries, the elderly population becoming much larger and the distribution of different parts of the population now being different from where it used to be. What might have been a very high demand area may not be the same now, but an area that might have been very small many years ago has now greatly expanded. We need to look again at the numbers based on the individual areas and on the demographic needs within those areas.

Is there not also an issue with discharging someone from psychiatric care and having supports for them? I can give the witness one example. For instance, I have a young lad who had a local authority apartment who, unfortunately, damaged it severely. He was inside a psychiatric facility for about eight weeks and then was discharged but ended up living on the street. Three months later, he was found dead. There was no co-ordination between services.

Is there a need for more work to be done in that area, when someone is discharged? I fully understand there is demand for beds and 100% occupancy, as Dr. Martin said. However, is there not a need for more co-ordination of services to make sure the backup support is available for the person when they are discharged?

There are two parts to what the Deputy has said. One relates to discharging somebody. We would not discharge somebody unless they were fit for discharge, and you would not discharge somebody because of bed pressures, unless they are fit for discharge. The bigger point refers to what follows discharge. From the community mental health team side of this, there will be many supports put in place as regards social workers, occupational therapists, day hospitals and so on.

There is a broader societal problem in terms of access to accommodation, employment, supported employment, training and so on. This is something community mental health teams and teams Dr. O'Connor spoke about earlier, work very closely on. However, we do not have very much control over these things, which is part of the difficulty. For people who have severe enduring mental illness, there may be certain mental health facilities within the community, but that only applies to a very small number of people. The vast majority of people coming out of hospital may be looking for accommodation, and while social workers, etc. would assist with that, we do not have access to accommodation.

This is where many of the problems are beyond what psychiatry or mental health reform can do. They are much broader societal and governmental issues. Absolutely, the mental health teams must liaise very closely with other agencies but, unfortunately, there are also broader issues at play.

Following on from that, with people being discharged and ending up homeless, is there not also a connection between people being discharged and then ending up homeless? I have been told by some people who work in the prison service, where many people end up, that in real terms, if there was adequate support in the psychiatric services, they would not be in prison. Have the witnesses come across this issue? There is also the issue of support within the prison service itself as regards medical care. Are the witnesses satisfied there is sufficient support within the prison service in that whole area?

That is a very specific area that is probably best answered by some of our forensic colleagues, but the Deputy is correct that many people do wind up in prison who would be far better managed within a mental health setting. Again, one of the difficulties is that, very often, they wind up within the prison system prior to going through a mental health service. That is one of the downsides. People get into difficulty and wind up in prison first. If we had broader, better resourced community services, we may be able to deflect that, but equally, if we had a system whereby it was clearly identified that their primary needs were mental health, a slightly different diversion process may be of benefit. However, this is probably something that is beyond the realm of this particular forum today.

I think Dr. O'Connor wanted to add something there.

I might give an example of a potential solution that is currently in place but is not everywhere. One of the things we have on our early intervention teams, who see people presenting with psychosis for the first time and look after them for three years, is employment specialists. These people work as part of the team, and some 50% of the people who present to our EIP teams come to us with no work or education. If you have an employment specialist on the team, 80% of those people find employment in the three years they are with them. This fundamentally changes your opportunities in terms of accommodations and all those other things. That is just one example of a potential solution we would like to see expanded. We also have those employment specialists on other teams, but again, there is variation across the country.

Going back to the bed issue, we now have a situation within the HSE where there are going to be six regions. Will there be co-ordination set up within each of the six regions on dealing with that issue and bed capacity?

The other issue relating to bed capacity is the actual allotted facilities which are outdated and in need of total refurbishment. They need to be renewed in the sense that not a lot of money has been put into them in recent years.

There are huge challenges in terms of bed capacity in our particular area. In our area in north Dublin we have the second lowest bed ratio in the country. In the case of a significant number of patients, for example, we have a much higher rate of detention under the Mental Health Act in our area because it is so hard to access a bed and patients are so acutely unwell. A single intervention that could be progressed with the work here, in the midst of all the medium- and longer-term interventions, would be to have a bed manager allocated. Many of the hours that the on call non-consultant hospital doctor, NCHD, is trying to cover in so many areas are spent trying to access and find a bed. If we had access to that on a regional basis, it would transform a significant component and, perhaps, the efficiency of the bed usage of the very small number that we do have at the moment while we are working towards assessing the capacity needs and improving that capacity.

Has there been an assessment of capacity needs and is there a plan, say a three-year plan, a five-year plan or a ten-year plan, to deal with that issue? We have been able to deal with it in a whole lot of areas such as, for instance, in relation to cancer care and maternity. Have we a five-year or a ten-year plan in relation to the psychiatric services for the entire country?

My understanding when I was on the national implementation and monitoring committee, NIMC, for Sharing the Vision, was that a component of this related to bed capacity analysis - and that was a couple of years ago - during which they assessed bed capacity and included private beds as well as public bed availability in determining the number of psychiatry beds available per population. So, it depends on how one views that.

Have we a plan in place now for over the next five years? Are clear targets set out for what we should achieve?

To my memory, a couple of years ago the view was that there were sufficient beds. I think a lot of clinicians would have-----

So Professor MacHale is saying there is no plan really in place at the moment.

I am not sure whether that has been updated but it would need to be.

Okay. I thank Professor MacHale.

I welcome all our guests to guests this morning and thank them for the work they do in a very difficult area. I agree with what has been said already in regard to accident and emergency departments. They are the wrong setting. They are too public and when people present themselves they are waiting too long anyway. They are simply not suitable and it needs to be addressed. If people are in trouble they simply cannot wait. In general terms, however, we must improve the area as it is the first point of call. In my county, most GPs direct patients with mental health issues to the accident and emergency department.

A number of weeks ago I raised the issue of a spike in suicides in my county. Obviously, this is extremely sad. It is all different age profiles. I believe we need to do something. I had been in touch with the Kerry county board. They are willing to help out. After the summer I will be approaching all other clubs and school principals to try to organise a series of meetings. If it helps one individual, it is a success story. In years gone by there were lot of public meetings, but that is gone. I am talking about mental health, suicide and drug addiction. In that context, perhaps the witnesses could help us out in Kerry with providing professionals. That would be great and I think it will be worth the effort. We are thinking about doing it in all the towns in Kerry so we probably will need a number of speakers.

Absolutely. A key component of the college's work is to provide guidance and expertise. We would be very much delighted to be supportive, to present and to engage in these public meetings, for sure.

I thank Professor MacHale.

One of the single biggest things that we need to do in terms of managing this overall problem is to educate. We can put all the services we want in place but, as someone mentioned earlier, it needs to start much earlier before people get into crisis. The area of suicide is extremely complex. It is not solely related to mental illness such as schizophrenia, depression and so forth, it can be related to substance use problems, to social problems or it can be done out of despair or anger. We never really know. One of the biggest things we can do is educate people on the supports that are available and then, of course, make sure those adequate supports are available. As Professor MacHale has said, we are always very happy to advise and provide any expertise we can.

I thank Dr. Martin.

Equally, Mental Health Reform would be willing to participate in those meetings too.

I echo what Dr. Martin said. Really there needs to be capacity building within communities about how to mind your mental health, what is mental health, how we seek help, and where do we go. People need to know. They need to have this in their arsenal. It should not be a mystery. It should not be a case of people who are now struggling being have to fight for information and having to navigate a system they are not familiar with. We need to make it easier, we need to make it clearer and we need to have a campaign so that it should not be a mystery. If people find themselves struggling or if their child is struggling, they should not have to fight for information. This is something we can do relatively easily. We can arm people with the knowledge they need to make the decisions they need to make and find the support they need. That really begins in the community and as early as possible, in schools, in sports clubs, in youth clubs and anywhere that we are bringing people together. It is really important.

I would echo that early intervention and prevention is critically important. Previously I worked in student mental health looking at referral pathways from education through to the health sector. We had mental health nurses on university campuses, we had signposting available, and availability of clinical and non-clinical support for people in the communities in which they were studying. That was so important in actually preventing student mental health crises and preventing suicidal thoughts and suicidal crises.

We have heard today about the Solace cafés providing that welcoming and non-clinical safe environment in the style of a café where people can go in the evenings or at weekends. They provide that range of support for people who need to use those services, including signposting, as we talked about, and peer support and community support. We have a number of cafés already open and more funding for additional cafés as well. We had an additional Solace café open this year in Limerick. I echo that real need for the preventative kind of work and the importance of multi-year sustainable funding to make that happen.

There are already some very extensive networks in the country and in rural life such as the GAA and the IFA. I have done work with both and I have to say that this was an education in itself because we forget quite how isolated rural life can sometimes be, particularly for the farming community. These are very extensive networks that one can link into by which we can provide information. It is really important that we do not forget there are things out there we can work with.

I thank our witnesses for coming here today to discuss this important topic. One thing that struck me in the presentations was that suicidal crisis assessment nurses, SCANs, are only in 14 counties. As people do not really cross over their county boundaries, perhaps we could have a comment on that.

The Solace cafés have been spoken about here quite a bit and I am very aware of the one in Limerick. I compliment all volunteers who work in these cafés because there are many people who go there on a daily basis and work with people. It is not easy but I know they have training. Around that education piece, should there be more training and support for people working in these settings?

In terms of access to accident and emergency departments, I can only speak of my experience of University Hospital Limerick, UHL, in Limerick. It has a small ward, ward 5B, which I have been in visiting two different people on a number of occasions. In one setting, a gentleman was there for quite a long time. He needed physiotherapy and other associated therapies and those services were not available. He was told, because he was in ward 5B, that he was not entitled to them. I fought that case for the gentleman in question and, eventually, he did get them. If you are in hospital with any sort of illness, you should be entitled to the full range of services.

The community access support team, CAST, project in Limerick is working well. The whole community piece, involving the Garda, nurses and psychiatric help, operates overnight. The Minister of State, Deputy Butler, is looking at expanding that service. I ask the witnesses to comment on that.

On people being able to access services, an ongoing issue we have faced for many years in the mental health services is people not having parity of esteem in terms of being able to access services. For example, as the Senator said, somebody who needs a physiotherapist or dietitian may be told to sort that out themselves because they are in mental health services. That is another issue we need to address in the broader context.

In terms of suicidal crisis assessment nurses, the expansion of services and how well they are working, maybe Professor MacHale or Dr. O'Connor would like to talk about that.

Dr. O'Connor will discuss SCANs because they are nurses in the community.

We have had a suicidal crisis assessment nurse in my area for the past ten years. They are scaling up. Essentially, the SCANs work really well. What happens is the GP can contact a SCAN who will come out to the GP practice, see the person there and do a comprehensive assessment. The SCAN will usually discuss the case with the psychiatrist and they will make a plan then about what happens from there. Often people do not come to the mental health team necessarily but they will be linked in with other resources in the community, and often the SCAN will follow up with the person on a number of occasions. The issue is variation and scaling. SCANs are available in some areas and not available in others. We need to have them available everywhere.

To comment on the patient in a psychiatry unit in an acute hospital setting, which is a challenge, the hope going forward is that the regional executive officer, REO, structure will allow us to be able to address the governance challenges in terms of those interfaces between mental health and physical health services by moving to a place where, rather than separating out mental health and physical health, the former is within the umbrella of health. The brain, as an organ, is just as much or as little under our control as the pancreas and the heart. We need to move away from that mind-body separation and take a different approach to psychiatry care. Many of these patients have medical and psychiatric comorbidities. That is the most common presentation, rather than the alternative. The REO structure, in theory, should allow us to make sure that all our patients have access to all the services they need through the healthcare system, rather than it being separated out into different governance structures.

The patient I mentioned could not access the pharmacy within the hospital for medication. They had to bring in their medication separately. That does not add up.

I would see that as a failure of management in terms of how we are providing systems of care.

The equity piece is huge. Our patients with serious mental illness die 25 years younger than members of the general population. They are at much higher risk and they have much less access.

I will speak to the CAST project. It published some recent evaluation findings and what it found so far is that the project had 181 diversions away from using section 12 of the Mental Health Act to keep somebody in custody, for example, in a Garda station. There is a huge issue here as regards the intersectionality of criminal justice and mental health. The interface between those means the Garda is called a lot of the time. Out of hours, the Garda is the de facto service that responds. Gardaí are tasked with bringing somebody further down the pathway.

Internationally, crisis intervention teams, such as the teams being rolled out under the CAST programme, show amazing results. The hope would be that the Department of Health and Department of justice, between them, could scale this up. It is not only about people accessing care. It is about making sure we do not divert people who are unwell into a prison system that cannot deal with their psychosocial issues and trauma, and that we take a health-led approach as opposed to a criminal justice approach. At the end of the day, we do not want to institutionalise people when what we should be doing is helping them. Ms O'Malley wanted to say something.

I will quickly chime in on the SCANs. Based on recent announcements, there has been a scaling up and these nurses will be in place in 18 counties, which is obviously wonderful to see. We would certainly echo and support that.

Solace cafés have been spoken about quite a bit, so I will not spend a huge amount of time discussing them. There is something really important there about the peer support they offer. Something that has come up in our lived experience is whether there is scope or space for a bit more peer support within the emergency department, in a separate space, because people speak powerfully about the impact it has to have someone there with empathy who can sit with you in the space and understand what it is like for you.

That is great. I thank Ms O'Malley.

As has been said, accident and emergency departments are not a suitable setting. I think we are all in agreement with that. A café in a separate area would certainly work.

Are there enough people being educated in the whole mental health area? I know of a nurse who graduated recently and, unfortunately, everyone in the class, bar one, went abroad to get experience in Australia, Canada or other places. They will come back eventually. I worry about whether there are enough staff being trained, and maybe enough psychiatrists, and also about the shortage of beds. How many beds are we short in the system overall?

The Minister of State, Deputy Butler, has brought the services a long way from where they were. I acknowledge the work she and her Department are doing.

In terms of the numbers of psychiatrists, we did some workforce planning a number of years ago and it was estimated we would need in the region of 835 consultant psychiatrists by 2030. We are way below that at the moment, and there is no sign of the figure getting anywhere close to that. That is a big issue. We need to take more people into training. We need more higher specialist training posts, such as the one Dr. Roberts is in because that is the post that then leads into a consultant role. Overall, that needs to be overhauled.

In terms of bed numbers, it would be irresponsible to say how many beds we need until we do a proper needs assessment of each individual area, looking at population, demographics, etc. We definitely need more but how many more and where they need to be are matters we need to decide.

We are coming to the end of our first round, but we will have a second round after Deputy Sherlock's contribution.

I thank the witnesses from Mental Health Reform and the College of Psychiatrists of Ireland. I apologise that I could not be here at the start of the session. I pay tribute to the work of both organisations. As we know, mental health has tended to be the poor relation in the health service for far too long. While there has been some progress, and it is important to acknowledge that and the work of the Minister of State, we still have a long journey to travel.

There are over 50,000 presentations to accident and emergency departments every year that involve mental health difficulties and we all recognise that accident and emergency departments are no place for these people. That reflects the scale of the challenge we face in terms of trying to put the right facilities in place.

I also very much want to welcome the reference by the College of Psychiatrists of Ireland that is a societal issue as well, in terms of poverty, housing and all those other issues, which all too often, do not get talked about with regards to mental health illnesses.

There has been a commitment to 24-7 psychiatric care in accident and emergency departments for over a decade now. Last year the roll-out of this was announced. How many accident and emergency departments are providing this service?

My second question is about the actual hours. There was the talk of 24-7 and then it seemed that it was only going to be until 2 a.m. and there would be a gap until 6 a.m. It is either 24-7 or it is not. I am sure that people with suicidal ideation present at all hours of the day and night, and particularly night. The third part of the question is about the physical infrastructure in accident and emergency departments. When I talk to hospitals, I find that some are trying to make an effort to have a room, but I am not hearing that there is any great push to make sure there are proper, purpose-built facilities to which people can be directed when they come in the doors of accident and emergency departments. I will start with the College of Psychiatrists of Ireland.

I will go in reverse order, if that is okay. I will start by looking at the accident and emergency facilities. Dr. Roberts may wish to speak to this.

I apologise if these questions have already been asked and I am repeating other questions. I thank Dr. Martin.

Ideally, we want to assess patients in a therapeutic environment. Many emergency departments have dedicated department of psychiatry assessment rooms, DPARs. Often, these facilities are not adequate. I have trained in three major Dublin hospitals. Two of them have had DPARs. They are encased in white plastic, with fluorescent strip lighting and a bench covered in vinyl that has been ripped. They were completely not therapeutic for any patient in any situation, be it mental illness or mental distress. Often, these rooms are located in the middle of the emergency department with windows for safety purposes - we get that - but you feel like you are sitting in a fish bowl, with nurses and patients walking on either side of you when you are in distress.

I chair the trainee committee in the college. It represents trainees across the country. A lot of my committee colleagues have emailed me to say that they often do not have access to these rooms. Sometimes, they are used as storerooms. Often, the doors are blocked by equipment or nursing stations, which is dangerous for patients and doctors. There is often a lack of facilities entirely. I have often had to have very sensitive conversations with patients with the magic blue curtain that, of course, is soundproof. There is literally nowhere else. I have often had to see adolescents who present to adult accident and emergency departments because they are over the age of 16. They are waiting in corridors. I find the family room, which is normally used to have very difficult conversations in more tragic circumstances, and tell people they can wait there. Unfortunately, the nursing manager then tells me that the room is needed to have the conversation with another family, so they have to go back out to the corridor.

In terms of adequate resourcing of DPARs, it is not just about having the rooms, it is having a therapeutic room that is low sensory and is obviously safe. There has to be either cameras or windows in order to keep patients and doctors safe. That is something that psychiatry does not directly influence. It is usually controlled by the governance structure of the accident and emergency department.

To come back to the question of 24-7, in theory, all accident and emergency departments have 24-7 psychiatry input, at one level, because there is usually a junior doctor available. That being said, that one junior doctor is insufficient to meet the need that is there for the vast majority of the time. Some places have varying numbers of specialist nurses, liaison nurses and so on and the Deputy is quite right that they work different hours, so that is not really 24-7. Dr O'Connor's service, for example, would be a very different case and maybe she might talk a little bit about that.

I work in a crisis resolution team. We take direct referrals for crisis. We see people on the same day, the following day or within three days. This is done by a multi-disciplinary team. The 24-7 service in accident and emergency departments is important but actually, the solutions are in the community. What we need to do is strengthen up the community so that people do not have to go to the accident and emergency department.

I completely agree. It is just that sometimes people do not have the wherewithal. I know that when people have come to me at very late hours I have made phone calls to ask where should I send somebody and I have not got an answer, so I end up sending them to the hospital, which is heartbreaking, but I take Dr. O'Connor's point on that.

I want to ask about the outreach teams. There are a number of different layers to community supports. We know that the psychiatric assertive outreach nurses are a part of the community-led approach. Yet, we know that in some parts of the country, particularly in south Dublin, Wicklow, Dublin, north Dublin, Wexford, Carlow, Kilkenny and south Tipperary, there are no assertive nursing outreach teams. What is the impact of not having those teams in place in those areas?

When we talk about outreach nurses it can mean many things. It can mean very proactive nurses on a community mental health team right up to something like the sort of service Dr. O'Connor describes where they are very proactive and able to get in very quickly.

Or rehab teams.

Yes, or rehabilitation teams, for example, which would look after people with severe and enduring mental illness. It is much more intensive, with smaller numbers of patients and so on. One of the difficulties is that we do not have adequately staffed teams to begin with. Then, as Dr. O'Connor was saying earlier, when we do find something that works, like for example, the service she has, that needs to be rolled out nationally. We need the bedrock of good community mental health teams, be they old age, adult, CAMHS, or whatever but also the additional services, the ones that really provide crisis intervention or rehabilitation. It is no good having one in Cork and one in Galway and one in north Dublin but not in south Dublin. What we really need is a national approach to rolling these out. We totally understand that it cannot all be done at once. We have to start somewhere and see if it works and find out what works. Once we have got something that works and we know it works well, that should be rolled out across the country.

As I have only a minute left I want to bring in Mental Health Reform for their response to the questions.

They have been well covered already, in a lot of ways. The point about the physical infrastructure and the need for a therapeutic environment in particular is hugely important. This comes up consistently with our lived-experience panels. Really, the need is for a trauma-informed space. I know it is an over-used term but it is about building a sense of safety, both physical and psychological safety, and prioritising relationships. In a situation with multiple staff all flying in different directions that relationship is not being built. That comes back to the need for peer support or someone who is able to sit with the person in those spaces and be the empathetic ear. That is critical.

I have more questions but I will come back in.

We are always so conscious of our time and rushing things. It would be remiss of me not to recognise the dedication and commitment of our mental health services and all the staff who work there every day under enormous pressure and the valuable work they do. I was also remiss in not welcoming the recruitment process for the ten specialist crisis nursing teams. It will make a huge difference in our accident and emergency departments to have that access to clinical nurse specialists and advanced nurse practitioners.

Dr. O'Connor made a really good point that had not occurred to me, so I am glad she did. It has been known for many years that the physical health of people with enduring mental health issues is affected and their life expectancy can be ten to 15 years shorter.

Yes.

They often live with poor health, maybe sometimes because of the medication they are on. We have a very successful chronic disease management programme, a model template in general practice now. I know sometimes it is a source of tension between psychiatry teams and general practice as to who takes responsibility. For example, if someone is put on lithium and to follow up on their physical. Would a structured programme in the community directed at people with enduring mental health issues be worthwhile?

Definitely, yes. The recommendation is shared care but, right now, we do not have a good infrastructure for sharing that care.

I will give an example in early intervention. I mentioned some of them earlier, but one of the pillars of early intervention is physical health. Everybody in our service gets screened. We try to intervene and support everybody. We need to work with their GPs to do that. They have the expertise in areas that I do not have the expertise.

It needs to be structured.

It is needs to be structured, supported and financed. If there could be something like chronic disease management and our patients could access that, that would make an amazing difference.

In my experience, obesity, high blood pressure, diabetes, smoking-----

It is metabolic syndrome and cardiovascular disease. Our patients smoke more.

Some of this is associated with the medication they are on.

Some of it is the medication but a lot of it is even beyond that. It is other things like activity levels, poor diet, poverty and all those things.

I used to do some work for a medical indemnity company. I do not any more - that is the statement of interest. One of the things that came up in general practice was litigation around the area of lithium treatment and inadequate management of kidney function and thyroid function, especially kidney function.

I have another question that is more exploratory. In the data that was produced, we see an increased prevalence of young people presenting in acute psychotic states to the emergency department because of cannabis use. Will one of the witnesses take that question for me?

Within our first episode teams, for 30% to 35% of young people presenting to us with a first episode who used illegal substances in the previous month, it was cannabis that was by far the most common one. There is a very strong association between cannabis and psychosis. The other thing is vapes. There was great work done here where the Oireachtas brought in legislation for HHC vapes, but they are still out there. They are still being used. We have seen a doubling every year of vape use in our population.

I am going to ask the witnesses a straight question. What is their view on decriminalisation and legalisation? If they feel they do not want to answer, that is fine because it is a political question. How do they feel about that?

Regarding our work in acute hospital settings, and patients and young people presenting with psychosis in the context of substance use, it is a potent powerful evidence-based trigger. We know from other countries' experiences that decriminalisation would undoubtedly increase the presentations for this vulnerable group of patients.

We need to focus on the health issues related to substance use rather than focusing too much on the legislation side of it.

Regarding the physical environment piece, which is mental health reform as well, we have mentioned this at this committee and at the disability committee, where we discuss children with special and additional needs, complex medical needs and the mental health arena. Dr. Roberts spoke very well about physical space that is appropriate but also separate from the milieu of the emergency room. Do any of the witnesses wish to comment on that again?

One of the big issues we need to look at is the environment. We have all said that today. The question arises is whether that should be in the emergency room at all or somewhere a bit more separate. We have talked about trauma-informed spaces and so on. What we maybe need to be looking at is something set aside. People will still go to the accident and emergency department, but it will maybe not be directly in the emergency room.

I thank the witnesses. I wish to go back to something that Ms Gillespie-Brown mentioned about non-clinical settings and the supports that can be available. Dr. Martin referenced GAA clubs and how we can leverage those existing networks to provide more of a holistic approach to well-being as opposed to a crisis response to mental health challenges when they arise. I firmly believe in preventative healthcare, whether that is physical healthcare or mental healthcare. The earlier it starts, the better.

We need to do a substantial piece of work around peer support in our communities. I will give an example. There is a remarkable peer support group in my own constituency called Blueballs Midlands. It is going to put me on commission if I keep talking about it. It is wonderful. It is a group of lads who support lads to go swimming in a lake. Every single one of them at one point have struggled with their mental health. They are on nobody's radar. The HSE did not know it was there until I told it. The local sports partnership just happened to turn up with a shelter for them one day when it realised the fantastic work they have been doing. It is not just in my constituency. It is in Dublin and Wexford. It is popping up all around the country. I also recently met with another group called Better Together. Again, it is peer support which is on the radar of the HSE and is now being funded for a pilot programme. It is working with people way outside of where it is geographically based.

On another occasion, a few of us took a trip over to Kyrie Farm in Kildare. How do we create a network of all of these groups that works and is effective? They are working in isolation. If we want to scale them up, how do we link them? They are going to have to link in with formal services at some point. We are going to have to get better around marketing them, which was mentioned earlier. They are doing such good work in our communities. How can we leverage them? How do we get them better connected? From the witnesses' perspectives, either from Mental Health Reform or the psychiatrists, how do they see that complementing the traditional - pardon the pun - clinical services?

Peer support is critical to complementing clinical services. I come from the Scottish sector. I have worked extensively with the Scottish Recovery Network that co-ordinated peer support with Suicide Prevention Scotland within the Scottish sector. The Scottish Recovery Network was active in universities, colleges and education settings. It was able to co-ordinate networks of peer support. That resulted in better outcomes for students experiencing mental health difficulties. We have good examples. For example, in the University of St. Andrews, there are peer support networks run by students who were experiencing mental health difficulties themselves. They had extremely good outcomes in terms of reduced mental health harm, suicidal ideation, etc. Coming from the Scottish sector, there is a real clear value in having a network that can co-ordinate these mental health peer support groups. As the Deputy said, they are incredibly important to people. We also have an extensive experience of peer support among our own members with Mental Health Reform, which can be very valuable. I will pass onto my colleagues to elaborate on that.

I will jump in very quickly. We have our lived experience networks. I am very familiar with Blueballs Midlands. A lot of our lived experience panel are linked in and speak very highly of it.

I should mention for gender balance that there is a women's group called Dips Don't Lie.

There is a piece of work to be done around linking them in. Given our role with our members being linked in and our lived experience networks, perhaps there is scope there for us to help support and be the link in that chain.

Brilliant.

It is important to point out that a lot of these responsive initiatives are usually set up to address a gap or lack. They are fighting for money. They are operating on a shoestring budget. They are working off annual contracts. Staff retention is a huge issue. People are going for mortgages or whatever, but they are going to sign a one-year contract. We need multi-annual funding. We need to be able to retain the staff. Regarding collaboration, there is work going on with the HSE. The HSE regions have started stakeholder forums with the voluntary and community sector. This is about understanding what is available in the spirit of Sláintecare. That is happening as well.

One of the things that I have learned and has struck me over the years as a consequence of being invited to speak to different groups - I reference two schools where I was invited to speak about suicide prevention and that kind of thing - was that the teaching staff were so clumsy around the subject. They did not know how to deal with it. I had to reassure them that this was not going to be about suicide. It was going to be about how we prepare young people to be aware of the challenges and how to manage them when they come.

In these two schools, the students picked the subject without the teachers knowing what subject they had chosen for this class. I was glad to have been invited to one of these schools. It was a class of 45 minutes. I thought the students were all very well adjusted. They were all in a hurry to leave the room. They brought some paraphernalia with them, information regarding access to services. One young guy stood back. He came forward when everybody else had gone away. I stood there with the three teaching staff. He came up and was ready to explode because he was harbouring everything we had discussed. He had made a plan to end his life. That day, he was intercepted. It is as much about interception as it is about a cure. It is hugely important to support people when they are in crisis. For that young fella, the circumstances were very simple. His parents had separated. He had a broken leg. He was out of sport. He felt he had no future. He would have been a statistic only for that interception. As I drove home that day - it was outside of my own county, although that makes no difference - I asked myself why the teaching staff did not have any concept or knowledge of how to identify a student who is struggling, where to take such a student if they do identify one, and what they should encourage them to do. I thought that was a failing.

More needs to be done on preparedness before students leave college. It is about giving them a toolkit, signposting them and eliminating stigma. If people find themselves presenting with any of those symptoms or challenges, they should not feel they will be pigeon-holed. They should be able to find the relevant supports. I do not know if the witnesses have anything to offer regarding what I have just said. I do not want to burden teaching staff with having to be able to do all of what I am suggesting but, by God, I was glad when I came home that day. I kept in contact with the school and that student went on to have a great life.

I am aware of a project in Jigsaw. The representatives of Mental Health Reform may be able to speak to this much better than I can. This project is called Neart and is being run in collaboration with the Department of education. The service is going into schools to provide training and support. I do not know all of the details but I am certainly aware of it. It is great to see that kind of collaboration across health and education. I think what the Deputy is highlighting is that this is a whole-of-society issue and that a whole-of-society response is required.

Yes, it is.

There is a lot of international learning that could take place. When I was working in the sector in Scotland, we worked with all colleges and universities in Scotland on student mental health agreements. This consolidated a lot of the work, bringing in student supports from right across the college or university. It allowed really easy access to information for students. They knew where to go. They could be signposted. They could be referred to clinics or GPs in the community. It also allowed for a sense of psychological safety within the campus environment. Some of those supports were introduced as the result of personal tragedies. For example, EmilyTest was the result of a young woman taking her own life. Her family developed EmilyTest, a programme across universities in Scotland. Another initiative is Ripple, which has been mentioned. Ripple is an option for colleges and universities to install on their IT networks so that, when people access websites relating to self-harm or suicide, they are directed to positive support. If they type certain terms into a search function on a network on which the college or university has installed the Ripple software, they are directed towards positive and appropriate supports. That takes away the initial difficulty around what they are experiencing. There is a lot we can learn from international good practice.

Our topic today was how emergency departments respond to patients presenting with mental illness. What is clear from what I am hearing is that we should prevent people ending up in emergency departments in the first place by strengthening community mental health teams, crisis intervention services and access to GP services. Where they do, there must be staff there to see them and separate facilities should be provided that are therapeutic and sensory. That piece has been missing from the discussion. It is good to put a spotlight on that. It is something we can continue to raise with the Minister and others.

Although he has now gone, I will pick up on something Deputy Martin Daly raised. I know this is separate from today's discussion but I think it is worth providing an alternative perspective on it. I refer to drug use and decriminalisation. The criminalisation of possessing small amounts of drugs for personal use has a devastating impact on people's lives. They can end up before the courts or in prison for the possession of small amounts of drugs for personal use. They can sometimes lose their jobs, homes or family support networks. That can have a devastating impact on people's mental health and well-being. It is worth providing an alternative perspective on that. I personally believe the Oireachtas and society needs to have a much wider discussion on cannabis. Having black markets where you do not know the potency or strength of the product provided definitely has health implications. Other countries have legalised, regulated and taxed cannabis. That provides more controlled access. It is potentially worth it for the State to establish an expert commission to look at this issue holistically. Deputy Daly brought up that matter and I just wanted to provide an alternative perspective.

In his opening statement, Dr. Martin mentioned staffing. It may be worth teasing that issue out a bit more. The written statement reads, "Whole Time Equivalent ceilings and Pay and Numbers policies have left teams unable to do their job to the best of their ability." Will Dr. Martin tell us a bit more about the impact those recruitment caps are having on services?

From the perspective of community health teams, where I work, although I am lucky enough to have a team that is fully resourced, many of my colleagues have teams that are missing core components. That could be a psychologist, an occupational therapist or a social worker. All of these do extremely important work within the context of providing holistic care to a patient. If you are missing any one part, your machine just does not work as well. One of the difficulties we are having is that, with the stroke of a pen, any posts unfilled on 31 December a number of years ago instantly vanished. That is, at best, a blunt instrument. At worst, it is the evisceration of a service. It meant that anyone who was unlucky enough not to have filled a post by the time that sledgehammer came down was left with a big gap. We are seeing this in the community mental health teams, in CAMHS and in a whole variety of other areas. It reduces not only the ability of the team to do its job properly, but the rapidity with which the team can see somebody. To come back to the emergency department situation, if somebody needs to be seen urgently, I am lucky in that I can see them tomorrow. I have got a full team. One of my colleagues might have a waiting list of three months because they do not have everybody they need. If somebody is seen in the emergency department and then referred to me, I can see them quickly. One of my colleagues may not be as lucky and may have a long waiting list. It has a huge impact on waiting lists. It has an impact on the ability of the team to do its job. At this stage, it is simply not feasible to leave posts unfilled in a service as vital as mental health services.

The HSE told the committee that staff shortages across psychiatry and mental health nursing and health and social care professionals directly affect the ability to provide timely assessment, maintain safe staffing levels and delivery consistent quality of care. While the HSE acknowledges the problem, does Dr. Martin think it is doing enough to address it?

Quite frankly, no. On the notion of capping services, we all understand there are budgets and that money is not infinite but, at the same time, you need to look at what is required. If you want to save money, you need to look at ways to do so that will not directly affect patient care.

It is critically important that those staff are there.

We are also seeing those staffing issues in the voluntary and community sector, obviously, in a slightly different way. They are coming up consistently. As has been highlighted, a lack of multi-annual funding in particular is the key driver of issues around staff retention. Our members constantly point out how difficult it is to recruit and retain staff.

We have been promised multi-annual funding for the HSE for many years.

Yes, multi-annual promises as well.

I want to pick up on the question that Deputy Daly posed to the Irish College of Psychiatrists with regard to the joint Oireachtas committee's report on drug policy reform. That very detailed report contains 161 recommendations, one of which relates to decriminalisation. I want to tease through the response to Deputy Daly's question to the effect that if there was decriminalisation, there would be an increase in presentations. I do not know whether Professor MacHale was referring to presentations to mental health services or emergency departments in that regard I hear what she is saying about causation. I have a different view on that, but I will not get into debating the matter. I want to ask about causation in the other direction. Dr. Martin referred to poverty and housing having a major impact in terms of people ending up in mental health distress or becoming ill. Surely addiction would be part of that as well. When people develop mental illnesses, for example, some of them some fall into addiction. There is shame and stigma associated with accessing healthcare at that point. We need to break down all barriers with regard to enabling people to access healthcare. I believe, as does the committee, following hundreds of hours of deliberation, that decriminalisation is one small part of breaking down the stigma to which I refer. What is the College of Psychiatrists of Ireland's view on that?

There are so many levels between the everything-and-nothing aspect of decriminalisation in terms of, for example, the soft redirection policy that is being used to divert people who are using small amounts of substances in the context of addiction to healthcare resourcing rather than putting them through the legal system and criminalising them. There are many aspects to this. A couple of years ago, there was a citizens' assembly in relation to this issue. Professor Mary Cannon, one of my colleagues, was very much involved in that process. She has done a lot of research on the impact of cannabis and the evidence base for cannabis in terms of triggering psychosis in people who are vulnerable but also, undoubtedly, in terms of increasing the rates. We have seen that in other jurisdictions.

This is a complicated area. To separate it into two areas of either decriminalising it completely or criminalising everyone is not how we would clinically work with patients. I agree 100% with the Deputy in terms of the need for healthcare interventions for people with addiction problems which are so commonly a comorbidity of the patients we see.

I share the view that decriminalisation should not be seen as a black or white issue. To decriminalise on its own and do nothing else would be profoundly and fundamentally wrong. That is what the recommendations in the report have clearly stated. My concern is that some psychiatrists have indicated publicly that they are opposed to decriminalisation. I regret that because it is a failure to engage with what criminalisation does. We need to make sure that we recognise that criminalisation is a barrier to accessing care and that if we decriminalise, we have to put an infrastructure in place around it.

The other thing we need to be clear on is that for a long time now the Government has talked about a health diversion scheme. That has not been put in place across the communities that I represent. If it is being put in place, it is certainly very patchy. There is a gap between what is being said publicly and what is happening on the ground.

There is a difference between decriminalisation and legalisation.

Absolutely. I am glad Dr. Rooney said that.

I refer to what has been found in other countries in the context of using a healthcare response. We have got prisons full of people who are non-violent, revolving-door offenders. They are in prison on minor drugs charges. All of their other needs are not being met because they are in prison. The decriminalisation piece works out that way as well. We are just institutionalising people unnecessarily. That difference between the what and the why in terms of whether we decriminalise or legalise it is quite marked.

That is a critical point. I am glad Dr. Rooney made it and I thank her for doing so.

This is an issue that we could probably dedicate many hours too and consider in a lot more detail. It was brought up, so it is good that it was responded to and considered.

I thank the witnesses for their time this morning. This has been quite a useful session in terms of shining a spotlight on services and putting forward some solutions on what can be done to improve outcomes. The committee has a keen interest in the area of mental health. I do not doubt that this is an issue we will return to and discuss in more detail. I thank representatives from the College of Psychiatrists of Ireland and Mental Health Reform for assisting us with our consideration of the issue of how hospital emergency departments respond to the needs of patients who present with mental health issues. The committee will give further consideration to and will decide how to proceed on these matters. The committee will now adjourn until next Tuesday, 14 July 2026, when we will meet in private session.