Tuesday, 28 April 1992
Dáil Éireann Debate
I want to make some relevant comments to illustrate why the Bill was necessary. Under existing law — the Mental Treatment Act, 1945, and amending Acts of 1958 and 1961 — around 3,000 people per annum are committed involuntarily to psychiatric institutions. These people are detained on the application of a relative and the certification of one or two doctors. They are detained under what are referred to as reception orders. These are not reception orders in the judicial sense but medical authorisations for the detention of persons. There are two types of order, a reception order and a temporary reception order, and two types of person to whom they apply, chargeable and private patients under the 1945 Act. Chargeable patients are those whose treatments are paid for out of public funds, while private patients pay for their own treatments. A temporary reception order lasts for up to six months and the reception order lasts for more than six months. The vast majority of people detained under these orders would be seriously ill, mentally disturbed and-or violent. I know many families dealing with such cases who suffer great stress and upset, often over a long period and in many instances with poor support or financial help. I acknowledge the difficulties suffered by these people and their families and I commend all those working in our psychiatric institutions who do so with great dedication and care.
The legislation which is under scrutiny relates to another group of people, those against whom detention orders are made but who are inappropriately held. In examining the 1945 Act, it is evident that  its provisions have been abused by causing people to be committed who were not insane, violent or dangerous. The motivation of the relative who committed them was at last questionable. Many of these people are committed to resolve a domestic dispute. In the cases with which I have been involved the provisions of the Act were misguidedly used as a solution to marital breakdown problems.
Some people will recall the Adjournment Debate last June during which I highlighted the situation of a young mother from County Dublin who had been forcibly removed from her home on a summer afternoon and detained in St. Patrick's Hospital. A week previously she had obtained a protection order against her husband. Her marriage was most unstable and unhappy and she was under great stress. Her need was for a legal separation and the possibility of making a life separate from her husband. Her need was not for a detention order which removed her to a mental hospital.
My experience of such cases goes back well before June last year. In 1975 I was contacted by two women, one a mother of seven from Galway and the other a mother of 12 from Dublin, with whose cases I became very familiar. They were both in marriages which were violent and damaging but at that time there was no acceptance that a woman could leave, even in a very bad marriage situation. This was prior to the enactment of the family law Acts by the Coalition Government in the seventies. One possible relief for many women was when their husbands deserted to England. This was very common in the seventies and was called divorce Irish-style. The only other relief these women got was when their husbands died and they became widows. While unhappy marriages were not as uncommon as now — or at least we were not aware of them — the hardship for the wife and mother living in a dead marriage was considerable and unrelenting. In that context I was personally involved with a number of cases, but specifically with the two I have mentioned.
After a first committal by their husbands,  the women endured what was in effect a revolving door syndrome, living in fear of being recommitted if they did not behave themselves. There were many in the seventies for whom the first battered wives home in Harcourt Street which opened in 1974 became a refuge from this type of home life and it represented their chance to make a new life with their children. The women I met through that refuge all recounted the same story. The signing doctors did not know them. They may have been neighbouring doctors and may have known the women vaguely but not as patients. They were very often the husband's GP. The doctors did not examine the women, most of whom had the awful experience of having the committal completed with the help of an ambulance and the Garda. Once inside the pshychiatric institution they were refused access to a telephone or permission to have visitors.
Many of those women afterwards lost custody of their children and they lived lives of isolation, feeling outcast because of their experience. When they tried to get an explanation from the hospital about their committal or to get copies of the documentation involved they came up against resilient opposition in every case. They were told they had no rights under the 1945 Act to such information.
Until the case of last June was brought to my attention it was my belief that amending legislation was in place which had introduced necessary safeguards against inappropriate or wrongful committal. I was most surprised to discover that this was not the case and that the 1945 Act, which had caused such difficulties to women in the seventies, was still the statute involved. I discovered that the 1981 Mental Services Act included the necessary reforms to prevent abuse but that it was never brought into force. The time for debate counted for nothing. I will return to that legislation later.
The cases I have referred to and the numerous other cases about which I have been contacted by individuals, psychiatric workers and relatives, show an urgent need for reform. It is the function  of law to provide clear guidance to those working in the psychiatric services and to provide firm safeguards against malpractice to users of the services. That is the purpose of this Bill. People with mental health problems are regrettably the poor relatives of the health services. Mental health has a low priority in terms of budgetary or monetary planning. There is a great need for broad-based reform which would concentrate on reducing overcrowding in our institutions, developing community facilities and changing the nature of our psychiatric institutions, many of which date back 200 years, from the isolationism of the past to greater integration for mentally ill people and their carers in the communities in which they live. I hope this debate focuses on those factors as well as on the provisions of the Bill. These guidelines are well documented in the 1984 Department of Health report, Planning For The Future.
I repeat that much too little has been done to implement the recommendations of the 1984 report, and successive Ministers for Health must stand indicted. I am concentrating here on an area which I feel is urgent and for which there is public concern. There has been unease over the years about abuse and the possibility of abuse in the 1945 Act. Incidents have been well documented in recent weeks by the media and by RTE. The need for urgent change has been identified. I appeal to all sides of the House to support my proposals and allow long overdue changes to be put in place.
The purpose of this Bill is to amend the Mental Treatment Acts, 1945 to 1961, where they deal with reception orders. In section 3 there is a misprint on line 14 in that the word “Part” should be substituted by “Sections” to read “Sections 14, 15 and 16 of the Principal Act”. This section aims to end the practice in the 1945 Act under which chargeable or public patients are treated differently from private patients. There is no reason for safeguards to be different as between sectors. The fundamental freedom of the individual is in question  in both instances and the basic principle demands equal and maximum safeguards for all, regardless of means.
Section 4 of the Bill provides for the establishment of mental health review boards, with one board in each health board area. These boards would consist of three persons, a barrister or solicitor, a medical practitioner and a lay person, all to be appointed by the Minister for Health. Section 5 deals with the work of the review board and how applications are made. Where an application for a review comes from a detainee, his or her parent, spouse or offspring or from the Minister for Health or the President of the High Court, the review cannot be refused under this section. However, it shall be at the discretion of the board to grant or refuse the review if made by some other person.
Section 6 deals with the outcome of the examination by the board and the decisions at which they may arrive. Section 7 involves a review of a person who has been conditionally discharged. Section 8 puts an onus on the board to seek a report from the medical officer in charge of each psychiatric centre for each person who has been in detention for a period of two years and make recommendations that he or she shall not be discharged or be discharged conditionally or transferred to care accommodation more suitable to his or her condition. Section 9 provides that the medical officer in charge of a psychiatric centre shall, in making the order, give that person a copy of the order and all documents relating to his or her detention. It also deals with providing documents on request after the person is discharged.
Section 10 repeals sections 259 and 260 of the Principal Act, 1945. Section 259 imposes a time bar on proceedings which may not be instituted after six months from the end of detention. This is quite an extraordinary limiting factor. It contrasts with normal periods of limitation for seeking civil actions, which for false imprisonment is six years and for actions for personal injuries, three years. Section 260 provides that civil proceedings cannot be taken under the 1945 Act  except with leave of the High Court, and that leave shall not be granted unless the High Court is satisfied that there are substantial grounds for contending that the person against whom such proceedings are being brought acted in bad faith or without reasonable care.
As outlined, I am sure nobody could disagree with the thrust of this Bill or deny that it deals with basic safeguards and protection of civil liberty. I am dealing with the Minister for Health who is as informed and, I feel certain, as concerned about what is happening as I am. I confidently hope that this Bill will not suffer the same fate as the 1981 Act either by being rejected in total or being cast and left in deep freeze to await indefinitely the necessary ministerial directions to put it into force. I want this House to deal with the reality of our mental health problems, acknowledging that the people concerned are not able to articulate their needs in many cases and depend heavily on legislators to upgrade legislation, safeguard their rights and improve their conditions.
This Bill cannot be answered with vague promises. I am not convinced that we need White or Green Papers in order to take the action that I have outlined as necessary. I would suggest to the Minister that the day is long gone when painting the railings of our psychiatric institutions can substitute for real fundamental changes in our services and in our law. I am particularly asking that the Minister, in his response, give an honest appraisal of the aborted 1981 Act in view of the fact that there is such a degree of public confusion and disbelief about that Act. There is no precedent for what happened with that legislation. What were the reasons it was never put into force? Are there sections that could be activated now through ministerial order? What was the outcome of the review of the legislation in the Department since 1981, as referred to in “Planning For The Future?”
I am aware that the medical profession opposed some of the provisions in that legislation. Doctors have told me that their fears and views have to be reasonably considered. One area of concern to  them is the need for speedy action in times of crisis, when a mentally ill person is being disruptive and violent. They say it would be a very difficult procedure to demand in the legislation that two GPs sign the certification after examination. This would be particularly difficult in the case of a crisis at night, at weekends or, as was stressed in the original debate in the 1981 Act, in a rural area. I do not believe that these are insurmountable problems. I accept that there is a difficulty in this regard and I suggest that an amendment be introduced on Committee Stage along the lines proposed by the Irish Council for Civil Liberties in their report of the Mental Health Bill, 1981, which states:
The Bill should provide crises intervention facilities to be made available by each Health Board. These might take the form of a team on stand-by in cases of emergency and include at least a Doctor and a Nurse suitably qualified. In such circumstances, two accredited members of a crises intervention team should be empowered to sign a recommendation for a reception under Section 19 in lieu of two G.P.s provided they were satisfied that a crisis genuinely existed.
I believe that a satisfactory provision could be put in place recognising the reality of these cases which, as I said earlier, represent the majority of the numbers at present detained annually. I am aware that this problem was encountered in amending legislation in the UK and elsewhere. They have resolved the problem satisfactorily and perhaps we should look at that before putting legislation in place.
Let us look for a moment at the Health (Mental Services) Act, 1981. Many of the provisions of this amending legislation undoubtedly would have contributed to the rights of detained persons, most notably in requiring the written recommendation of two registered general practitioners for a reception order and dropping the distinction between public and private patients in this regard. Under the 1945 Act, which came into force in  1947, the procedure that applies to public patients is different from that applying to private patients. This is unacceptable to public opinion and it was recommended that it be dropped in the 1981 Act.
The 1981 Act also requires that a general practitioner who makes a recommendation is required to inform the person to whom it relates of his intention. The Act required the medical officer in charge of the psychiatric centre to give the person detained a copy of the reception order together with the recommendation for reception and a copy of any extension order. The Act also requires the medical officer to give the person a statement of his rights and entitlements under the Act. He is further obliged to provide persons detained with the necessary facilities for writing, delivering and posting letters. We would all agree I am sure, that these measures should be a fundamental right of any patient detained. The Act also proposed the abolition of the time limit on the institution of court proceedings, as I propose in my amending Private Members' Bill.
While the 1981 Act was an improved measure to protect essential civil liberties, it has to be acknowledged that it did not provide the complete answer for legislative reform, as one would have expected from the first major reforming legislation on mental health in 35 years. For instance, it failed to define mental disorder, it did not lay down the criteria for what should be considered an examination and alternatives to committal were not discussed.
The Bill is a short document of some 20 pages, reflecting the narrowness of its scope, especially in comparison with the existing legislation which is a 130 page publication and which will be repealed by the Bill.
The Irish Council for Civil Liberties feel that major safeguards and protection  need to be included in law and, therefore, subject to full open debate, rather than subject to ministerial regulations or local practice. They said:
I now wish to deal with two related areas. I am seriously concerned that no reports of the inspector of mental hospitals have been published since 1979. The Minister will be aware that we have debated this already in this House. I now see how this is related to the 1981 Act. Interestingly enough, that Act dropped the requirement in sections 247 and 248 of the 1945 Act that the Minister and the Oireachtas would receive an annual report on all mental institutions, including the Central Mental Hospital and private mental hospitals and on the care of patients in all those institutions. The anomaly we now have is that no reports have been issued by the inspector since 1982, which dealt with the years up to 1979. It seems that the inspector of mental hospitals is operating under the provisions of the 1981 Act, which did not come into force and is ignoring entirely his obligations under the 1945 Act where this is his statutory duty. This is an extraordinary situation and I am sure the Minister must agree that it must be resolved right away.
I question how mental health services can function properly without the statistics, the facts and figures, contained in these reports. Indeed, I read the last one published in 1982 and found it informative and reassuring. However, I would have to question what access people have to statistics if they cannot put their hands on an up-to-date report which one would expect in this important area.
Article 5 (1) (e) states two broad conditions for depriving a person of liberty on mental health grounds and the detention must be in accordance with a procedure prescribed by law and must be a lawful detention of a person of unsound mind. The European Court of Human Rights held in the Wintwerp case, 1979, that any measure depriving a person of his liberty should issue and be executed by an appropriate authority and should not be arbitrary; paragraph 37 requires that the domestic law procedure be fair and proper and that it be complied with. We are not doing this under the 1945 Act and, therefore, we are in contravention of our obligations under the European Convention on Human Rights.
Everyone who is deprived of his liberty by a detention shall be entitled to take proceedings by which the lawfulness of his detention shall be decided speedily by a court and his release ordered if the detention is not lawful.
It, therefore, seems appropriate in the interest of carrying out our obligations under the European Convention on Human Rights that Irish legislators should entertain and enact the proposls to establish mental health review boards, as is proposed in my Bill.
The debate on this Private Members' Bill will be watched very carefully tonight, tomorrow night and next week by a number of groups and interested parties. Indeed, the Minister's response tonight is very much anticipated. We in Fine Gael are committed to this Bill and we sincerely hope it will be accepted and will be given effect in legislation, but there is broad consensus among those who are equally concerned. Among the groups who support the measures in the Bill is Women's Aid, which operate refuges in and outside Dublin. In an article in The Irish Times in June 1991 Ms.  McDermott commented on the reality for some women who come to her refuge:
Ms. McDermott said that the use of threats of committal by husbands against their wives was a large problem so far as Women's Aid was concerned. The threat was usually coupled with a warning that if the women were committed, they would lose their children.
In some cases, the man would do things — like hiding the woman's shoes — to make her gradually doubt her own sanity. In other cases, years of stress, beatings and threats would lead the woman to seek medication and this in itself would become another piece of evidence that she was mentally ill.
Ms McDermott said she supported proposals for change. In a press release Ms. McDermott said Women's Aid is an organisation that provides support and accommodation for women who have been physically, mentally and sexually abused in their homes and they welcomed the Mental Treatment (Amendment) Bill 1992. The press release states:
Over the last 18 years we have dealt with a number of women who have suffered under the 1945 Mental Health Act. It is our experience that women who have sought barring orders against violent husbands have often found themselves committed to a psychiatric institution against their will.
Therefore we urge all political parties to support the Mental Treatment (Amendment) Bill, 1992, proposed by Fine Gael to ensure that proper legislation  is enacted to amend the law which patently does not afford protection to this country's citizens. This Act must be amended to ensure that it cannot be used as a threat to women who attempt to protect themselves from violent husbands in the invoking of current legislation in the family law area.
It is interesting to note a common thread running through the reports of people who are the victims of that legislation. Other groups and people have supported it. In a “Today Tonight” programme, psychiatrist Professor Anthony Clare was in no doubt whatever about the need for reform of the 1945 Act. He talked about the need for transition from the custodial form of treatment which has been traditional in this country to the therapeutic which is now accepted in modern medicine to be the correct approach. He said his medical colleagues had no cause to fear change.
Involuntary commital is traumatic for both the patient and family and unfortunately in some cases it is necessary. However, it need not be the only way. Ideally one should aim for voluntary admission as it is not hard to understand that treatment received voluntarily is much more likely to be effective. More attention might be paid to ways of exploring helpful routes to voluntary admission. For instance, our experience is that self help groups can help people to acknowledge the need for psychiatric care.
The administrator of the Schizophrenia Association of Ireland went on to give details of the support services they would like. Even though they are a group who would have first-hand experience of the  need for crisis detention, they accept there is need for reform and that involuntary committal should not be the first line of action.
In the past year a separate organisation has been formed, called Wrongfully Institutionalised People, who are campaigning for change and support for this measure. They know they cannot do anything to redress the injustices that have been perpetrated against them over the years but they are determined that this practice ceases and that other people will not be victimised in the same way as they were. I would like to quote another psychiatrist, Dr. Michael Corry, who feels very strongly about this Act. In a letter in The Irish Times of 8 March 1990 he said:
Why doctors co-operate with this process is more than just a matter for their own conscience. It places them in an untenable position, as in essence, whether they like it or not, they fulfil a powerful political role in society which overrides their medical one. It raises three fundamental questions which cannot be fudged, namely: how is it possible to treat someone against their will? How can an atmosphere of trust develop between the doctor and his client when there is power on one side and fear on the other? How is it possible to expect human beings who are psychologically distressed to seek out help when they are afraid they might “get locked up”?
Forced confinement and forced administration of treatment, often hazardous and of dubious efficacy, gives psychiatry unbelievable powers that surely make it the most powerful body in the land. It is difficult to imagine that a professional body has such discretionary authority. Notwithstanding the fact that “judgements” are based on variable and subjective criteria.
I hope I have illustrated the case deserving of action. This legislation was not prepared in any cavalier way. This is an area in which I have a very strong and  keen interest and I believe there is a definite need for this debate and for action. The issues we have to attempt to resolve are to bring equity and fairness into our application of this law, to bring in safeguards and to aim to prevent abuse. I accept that while aiming to prevent abuse, there will possibly be a margin in which there will be some abuse, but the least, we should have is proper accountabilty and proper redress for those who feel they have been wronged.
I am calling for a new emphasis on improvements in the psychiatric services and for an enlightened approach to the treatment of mentally ill people. Above all we need to debate this matter at every level, taking all interests into account. Finally, there is an overwhelming need for a single piece of mental health legislation and a comprehensive consumer-friendly, reader-friendly patients rights guide which should be readily available to all those involved, whether as providers or consumers, in the psychiatric service.
Minister for Health (Dr. O'Connell): At the outset I would like to congratulate Deputy Nuala Fennell on her initiative in bringing forward this Bill. I am aware of her genuine concern in this area, her determination to rectify the serious anomalies in existing legislation and to protect the rights of patients.
I have considerable sympathy with the objectives of the Bill as proposed. As a general practitioner and a Deputy I have been concerned for many years now with the quality of our mental health services and the legislative framework for the delivery of these services. I have been giving this matter some very careful consideration since assuming office just over ten weeks ago and I am satisfied that the pace of developments in the service needs to be accelerated. Also, the law in this area needs to be up-dated to keep pace with and facilitate the service developments and to conform to modern concepts in relation to the rights of the individual and, of course, the protection of these rights. For too long now the patients in our psychiatric hospitals have  had to endure sub-standard conditions and they did not enjoy the benefits of the improvements generally in the health services. For too long it had been assumed that there was no hope and no future for our long-stay patients and that their lot was only more of the grinding boredom, humiliation and sometimes even neglect in our old Victorian custodial style mental institutions.
Thankfully, however, there has been considerable change in the past decade or so and the numbers in psychiatric hospitals continue to fall. For example, in 1984 there were 11,613 persons in public psychiatric hospitals while the figure for 1990, six years later, was 7,817 — a reduction of 33 per cent. This reduction in the numbers in our psychiatric hospitals has been accompanied by a considerable expansion of community-based facilities. Again, for example, the number of day hospitals increased from 32 in 1984 to 97 in 1990. The increase in the number of hostels over this period was from 121 to 292.
So far as the legislative base is concerned a comprehensive Mental Health Act had been introduced in 1945 and while it was an enlightened piece of legislation in its day, it dated rapidly. It is now out of keeping with the latest concepts of service delivery and with our obligations under international conventions and agreements.
I am happy to say that I have now submitted to Government a draft Green Paper on the mental health services which deals with both service issues and the legal framework. The Government's intention to publish this document was announced publicly by me on 15 April. I have decided on this course of action for a number of reasons.
First, in my view there is a strong link between the quality of the service, the manner of its delivery and the legal framework. The service and the law are a “chicken and egg” situation and I am anxious that they be considered as part of an overall approach rather than as two separate or distinct issues.
Second, while within the medical profession there is fairly general agreement  on the type of service to which we should aspire, some reservations have been expressed on certain aspects of the proposals for service delivery. Consequently, I am anxious that there should be the fullest possible discussion of our approaches to service delivery so that we may decide on the best option and then proceed with confidence to put the new style service in place.
Third, in the area of legislation I know there is a fair degree of agreement in principle that the rights of the individual must receive better protection and that there should be stronger safeguards to ensure this. However, when we get down to specific issues such as the duration of detention orders, rights of appeal etc., there can be considerable debate as to the most appropriate approach.
Finally, I have been aware for sometime that there has been some public disquiet particularly in the area of involuntary detention. I am anxious therefore to ensure that everybody is given an opportunity to put forward their point of view so that I can take all shades of opinion into account when bringing forward specific proposals.
It is for these reasons that I feel the best approach at this stage is the publication of the discussion document. I know that some people feel that the matter is so urgent that we should push for a faster solution but I think the sheer complexity of the issues dictate otherwise. I am conscious of the fact that a Mental Health Act was passed in 1981 but never brought into force. I do not propose to go into detail on the reasons for this here tonight but I am fairly sure that if the process of discussion and consultation which I am now proposing had taken place in 1981 we would not subsequently have had such difficulty with that Act. I am also convinced that a focused discussion and structured debate on the key issues will of themselves stimulate a greater interest in the development of our mental health services and make all concerned more aware of patients' rights and the need to protect them. I hope the debate will inform present and future patients as to  their rights and make them more confident in asserting them.
As I said at the outset I have considerable sympathy with the objectives of the Bill before us. However, I feel it is far too narrow in its focus and does not really address the issues which Deputy Fennell claims it does. I would be fairly happy with its general approach to the protection of the rights of patients who are long term patients or who are in a position to initiate action on their own behalf or to have someone do it for them. I would have some difficulty with the details of the provisions. For example, I think it falls down badly on the question of the admission of patients.
It is important to remember that the vast majority of patients — about 90 per cent — receive treatment for psychiatric conditions on a voluntary basis and it is my firm belief that such patients should be able to obtain treatment without any legal formalities in the same way as patients suffering from physical conditions.
Deputy Fennell has mentioned the fact that husbands can have their wives committed to psychiatric hospitals on the flimsiest of excuses. She was quite rightly very concerned a few months ago at allegations that a wife was committed by her husband to a private psychiatric hospital. I believe there is a need for an automatic review at a very early stage of all nonvoluntary admissions to psychiatric hospitals. Again the manner in which this review should be undertaken needs to be considered very carefully.
One of the problems I always had with the 1945 Act is its scope and imprecision on the grounds on which a person could be committed. I am quite satisfied that any new legislation in this area will have to define much more clearly the grounds on which a person can be committed and the medical personnel involved will then have to be much more specific as to the reasons for a detention. This would be one of the most effective safeguards for individuals.
In general then I can say that I have no difficulty with the objectives of the Bill but I have considerable reservations  on the details and the narrow approach to mental health legislation it indicates. For those reasons the Government will be opposing the Bill on Second Stage. I want to make it absolutely clear, however, that our objections are not based on any negative attitude to the issues themselves but rather on our firm belief that they need to be considered in a much more comprehensive and detailed manner. This we are proceeding to do as quickly as possible.
The 1945 Act provides for the apointment of an inspector of mental hospitals. One of the inspector's principal tasks is to visit each mental hospital every year and to make a report to the Minister of the conditions in the hospital and the services provided. This provision was not included in the 1981 Act and for a variety of reasons inspections were not made for a number of years in the eighties. These inspections were resumed on a formal and comprehensive basis in 1988 and one of the first documents I studied on arriving in the Department of Health was the report of the inspections for 1988 and 1989. I have to say, and I regret that I have to say this, I was quite frankly appalled at some of what I read in these reports.
Some of the conditions described by the inspector were extremely disquieting and should have no place in a modern day health service. What was even more disturbing was the fact that in so many instances the level of service provided fell so far short of the standards one would reasonably expect to see in place.
I accept that the excuse for some of this was due to resourcing difficulties but the standards of accommodation and quality of service varied so greatly that much of it cannot be blamed simply on lack of resources. By contrast many of the services described are of a relatively high order and are a credit to the dedication and commitment of the staff involved at all levels. It was this which made the services which fell so far short of what might reasonably be expected all the more telling and inexcusable.
I have now written on a formal basis to each health board and asked for a  report on an urgent basis on the steps they have taken to remedy the defects outlined by the inspector. I have also written and asked for an immediate review of all the fire precautions in every mental hospital. I appreciate that the reports for 1990 and 1991 which are not yet finalised show considerable improvements and I will have it as an urgent priority that services in all areas are improved to acceptable standards. I should say also that I have asked for a record of all deaths and a report on injuries to mental patients as a result of accidents in each mental hospital in each of the past five years.
I am arranging at present to have the reports for 1988 and 1989 presented to both Houses of the Oireachtas and the President of the High Court in accordance with the 1945 Act. The publication of this report should also provide considerable material for a wide ranging debate on our psychiatric services.
The conditions and services described in the reports made me acutely aware that more than technical legislative changes are needed — necessary though this may be — to provide patients with the care and treatment which is their right. It is for this reason that I intend in the Green Paper to deal with both service developments and legislative requirements.
Services for persons with a mental illness have traditionally been provided in large Victorian style buildings which were largely isolated from the community and from the rest of the health services. In 1981 a study group was established to review the services and to provide a policy framework for the future development of the service. This group reported in 1984 with the now well known document “Planning for the Future”. The report recommended that the hospitalised and isolated service should be replaced by a service which was to be based in the community to provide in a comprehensive way for the needs of those with a mental illness and which was integrated with the health services generally.
I am pleased to be able to say that much has been done in many areas to  transform the service as recommended in “Planning for the Future” and, indeed, many of the radical recommendations in that report have proved eminently feasible in practice. However, the pace of change and development has been uneven across the country and much still needs to be done. In addition, some of the report's recommendations have proved less easy to implement in practice and the twin tasks of developing a community oriented service while at the same time having to maintain much of the old hospital system have proved less than easy.
Eight years on from the publication of “Planning for the Future” I think it is necessary for us to take stock of the situation, to evaluate what has been achieved and to consider how we move forward from here. The Green Paper will address these issues and facilitate a discussion on the way forward.
As the Green Paper has not yet been fully considered by the Government I cannot say precisely what it will contain but in relation to service provision and development I can say that it will deal with a wide range of issues including the extent to which the recommendations generally of Planning for the Future have been met; the specific service requirements of different categories of patients, such as child and adolescent psychiatry, persons with a mental handicap in the psychiatric hospitals, alcohol related problems, severly disturbed patients, mentally disordered offenders and the elderly mentally infirm. In addition, it will deal with issues, such as the promotion of positive mental health — something to which I attach the highest priority — and the personnel implications of a changing service.
It would be my wish and ambition that the service for persons with a mental illness would be of a very high standard, would of itself strive to maintain and improve these standards in line with advances in medical science and techniques and would reduce significantly the need for legislation to regulate it.
I would now like to address the question  of mental health legislation itself. I have already pointed out that I believe there is little, if any, need for any specific legislative procedures for the vast majority of persons with a mental disorder and who seek treatment on a voluntary basis. They should be treated in the same way as any person seeking treatment for a physical ailment.
However, as matters stand at present there is, unfortunately, a need to detain some persons for treatment on an involuntary basis and it is necessary to have effective legal provisions to ensure that the rights and dignity of such persons are fully protected. At the same time, however, we have to ensure that the legislation does not present a barrier to any person receiving adequate care and treatment or that the administrative and legal framework is not unduly unwieldy or cumbersome.
The evidence available to us suggests that we have a relatively high level of involuntary admissions to psychiatric hospitals by comparison to other developed health services so it would seem that there is plenty of scope for us to reduce considerably our numbers of 3,000 or so per year. Many of these patients should be capable of being treated on a voluntary basis.
I have already mentioned some of the matters which I feel need to be addressed to provide proper legal safeguards against unnecessary admission. I will be putting forward ideas for discussion on these issues and many others in the Green Paper.
I am also extremely conscious of our obligations under international conventions and agreements such as those of the United Nations and the Council of Europe. The introduction of new legislation will give us the opportunity to ensure that our laws are fully in accord with our obligations in this regard. The issues which I will be considering in the Green Paper will also include: the criteria for involuntary admission which I have already mentioned; the procedures for involuntary admission which are of crucial importance and at the very heart of what Deputy Fennell is seeking to  achieve in this Bill; the duration of detention orders and conditions for their extension; procedures and arrangements for the review of admission and detention orders; arrangements in relation to offenders who are suffering from a mental disorder; the possibilities of having legal provisions for care and supervision outside of the hospital setting; arrangements for the protection of the rights of mentally disordered persons — these would include matters such as access to information and records, representation and legal aid, codes of practice and any other sensible and practicable arrangements which may be thought necessary or desirable; and considerable revisions will also need to be made to the law in relation to the administration and delivery of the service in the light of the developments which have taken place over the past few years.
What I have outlined here demonstrates my intention and that of the Government to undertake the most comprehensive review of our psychiatric services and we wish to ensure that all interested parties and individuals are given the fullest opportunity to contribute to this review. I will give ample time for the due consideration of the many issues involved but I warn that I am very anxious to make rapid progress on this matter and want to be in a position to bring forward definite proposals at the earliest possible date. Consequently, I will be expecting all interested parties to address themselves urgently to the various issues that need to be considered.
After 47 years it is only to be expected that the law on mental treatment would need to be updated. After 47 years it is only to be expected that the scale and scope of this revision would need to be wide ranging and radical. That is what I, as Minister for Health, and this Government are determined to do. I know that the task is not going to be easy and that the many conflicting views as to the correct approach will have to be teased out and reconciled to the greatest possible extent. I can fully appreciate these views and can understand the bona fides of the persons putting them forward but I will  be asking everyone involved to try as far as possible to see the issues from the point of view of the patients. If we can succeed in doing this I am confident that at the end of the day we will have a more effective, caring and acceptable mental health service which will be of benefit not only to the patients who are our primary concern but also to all who work in providing the service and to our society as a whole.
I honestly believe that this major overall approach is needed and for this reason I have difficulties with the limited approach being adopted in this Bill. I sympathise with what it is trying to do but its scope is far too narrow. It is for this reason that the Government are opposing the Bill.
Deputy Fennell asked about the 1981 Act and I should like to make two points in regard to it. Seven different Ministers have held this office since that Act was passed. Deputy Woods, Deputies Barry Desmond and Eileen Desmond, Deputy John Boland, Deputy O'Hanlon, Deputy O'Rourke and myself.
Dr. O'Connell: There were five different administrations in the same period. There were certain technical defects in the Bill as passed which would have caused difficulties if it had been implemented. We have a choice of amending the 1981 Act to remedy these defects or to introduce a new Bill. The main reason for our decision to prepare new legislation is because the provisions of the 1981 Act are now inadequate in the light of our obligations under the European Convention on Human Rights.
An example may help to explain the shortcomings of the 1981 Act. It provided only for a review of the detention orders on application from a patient or relative. Under the European Convention we are obliged to have a review of every detention order, irrespective of whether the detained person applies. Deputy Fennell's Bill, which repeats the review provisions of the 1981 Act, would  not meet our obligations under the European Convention. The issue of review will be discussed in great detail in the Green Paper. Several developments have also outstripped the framework of the 1981 Act and make it inadequate to deal with the challenge of a community based psychiatric service, as proposed in the document, Planning for the Future.
A major advantage of this debate at this time is that it gives me a fortuitous and unexpected opportunity to hear the views of Deputies on this important issue. I will be following the debate very closely and will be very receptive to any constructive or innovative ideas which emerge.
Mr. Ferris: I propose to share my time with my colleague, Deputy Moynihan, who is an expert of 37 years' standing in the care of psychiatric patients as he was a psychiatric nurse before he entered the hallowed walls of Seanad Éireann and Dáil Éireann. It would be of benefit to the Minister in particular to hear the views of somebody like Deputy Moynihan who worked at the coalface, so to speak, of the delivery of mental health services to the disadvantaged people in the community suffering from mental illness and in need of compassionate care and attention. I am heartened by the Minister's response to the debate on this Bill.
Mr. Ferris: The Labour Party welcome the introduction of this Bill by Deputy Fennell. However, it is merely tinkering with the whole area of mental health care which requires urgent overhaul and redefinition, as the Minister has been saying over the last 30 minutes or so.
The Labour Party believe that the area of mental health care and treatment has been neglected by consecutive Governments and Ministers of all parties, with the possible exception of the programme announced in the document issued by  former Deputy Barry Desmond when he was Minister for Health. When he proposed that document for discussion it led to controversy because there was a certain rationalisation involved in the whole programme in planning for the future, a rationalisation which, as the Minister admitted, has taken place in the tremendous reduction of patients who, up to then, had been confined — and were expected to be confined — in mental institutions. With proper treatment, care and support these patients would be healthier and happier in the community. Of course, irrespective of our commitments, there has never been sufficient involvement at Government level to ensure that sufficient funds are available. Community based care is expensive although it is the proper way forward in the treatment of people's mental health.
Members who have been involved in the health services and on health boards were privileged to visit these Victorian institutions and see the changes, the lowering of the walls, the opening of the gates and the integration of the inmates in the community, even on a daily basis, and returning to the institution at night for care and attention. It must have benefited these people to go back to the community from which they had come initially and to meet people regularly. Welcome changes have taken place but, as the Minister said, there are still some extraordinarily difficult and intolerable situations which are unacceptable. I know — and this will be confirmed by professionals like Deputy Moynihan — that in spite of the best care, attention and dedication, this level of nursing care is the most difficult of all because an appreciation by the patient is not normally forthcoming. A relationship which is contrary to a normal working relationship can build up between a patient and nurse or between the patient and the resident medical officer. There can be a love/hate relationship or an aggressiveness and a lack of control, through no fault of the patient, in regard to mental care and institutions which at times makes it impossible to keep the standard of hygiene and cleanliness at the level  we would like. However, that does not remove the obligation from us to ensure that the best service is available to this category of patient.
The Labour Party congratulate Deputy Fennell for her work in this area. She has shown commitment and concern and has identified here and in the media specific cases which should not happen in any society if we have any regard for ourselves or the freedom and rights of other people. We maintain that the provisions of the Bill as outlined by Deputy Fennell really only scratch the surface. I realise, as a Member who published a Private Members' Bill, the difficulties faced by Members of the Opposition who try to have a Bill accepted by the Government. Part of this democratic process is to trigger action from the Government. At least the Minister has tonight indicated that action in this area is on the way. The Labour Party say that provision is being made for a very minimum review of what urgently requires review. We were encouraged by the Minister's positive response to the Bill earlier this month at the annual general meeting of the Psychiatric Nurses Association. The Minister than appeared to be aware, as he has confirmed tonight, that legislation covering mental treatment is outdated and urgently requires detailed and comprehensive review. The Minister stated that he was proposing within the Department to make changes and was in the process of preparing a Green Paper. We welcome the Minister's statement tonight that proposals in relation to mental treatment are at present before Cabinet. As a party, we sincerely hope that the Green Paper will be published with the Government's approval, as soon as possible.
I ask the Minister to give a specific date for publication of the Green Paper, if at all possible before the end of this debate. The Labour Party know that there are other demands on the Government's time, on the Attorney General's time and on the time of everybody else, but we ask that a date be put on the publication of the Green Paper because the 1945 Mental Treatment Act is completely inadequate for today's needs and requirements. A  degree of urgency is therefore attached to the presentation of the Green Paper. It is imperative that the Minister give a time limit for the publication so that a full discussion between all interested parties throughout the country may take place. I know that an excellent, heartwarming debate would be forthcoming from all in the Oireachtas, from the agencies, from the health boards and from the professionals involved in the area of mental health care.
Those of us who have been involved with any of those people know of their commitment. They welcomed the process initiated in the publication of Planning for the Future and they have been implementing that process within the resources available to them. Those resources are limited and often mental health has to compete for resources with other more demanding and more glamourous health services such as acute hospital services. We cannot allow other needs to interfere with this priority service.
The Labour Party realise the need to provide for greater safeguards against inappropiate detention in psychiatric hospitals the specific point with which Deputy Fennell is concerned. We all share the Deputy's concern. Between 1980 and 1990 there were almost 33,000 involuntary admissions to mental institutions. Of that number 28,000 were released within six months of admission. Immediately a major question is raised — 28,000 out of 33,000 were very quickly assessed as being fit for reintroduction into the community. About 2,500 people are committed involuntarily to psychiatric hospitals each year——
Mr. Ferris: In other words, 11 per cent of all admissions are involuntary committals. That is according to the Minister's own statistics. Unfortunately, the statistics on involuntary admissions do not provide the additional and very important information that would indicate whether they were first-time patient  admissions. That is information that we would all require, information that I am quite sure Deputy Fennell requires. The Labour Party maintain that for first-time admissions institutions should be required, by law if necessary, to carry out an immediate interim assessment of the patient to ensure that an injustice has not been carried out. I hope that that provision will be contained in the Green Paper. Such an assessment would have to be immediate — it could not be carried out the day after admission or two or three days after admission.
My party want to ensure that the professional consultation be available immediately on a one to one basis between the patient and a psychiatrist. It should be carried out in the privacy, seclusion and comfort of a room that is user-friendly and it should not be carried out in the presence of a member of the Garda Síochána, ambulance staff or in other intimidating circumstances. Any new legislation should contain that provision. We would hope that any concerns expressed by a patient during such consultation could be professionally and properly investigated by the authorities to ensure that no injustice has been done to the patient.
We must also ensure that all patients be given the fullest information on their rights and have access to outside contact, to telephones and to any agency they might wish to be in touch with. Deputy Fennell made this point adequately.
The present position is inadequate. The people involved are not criminals but they are treated as if they are. Those people are, at most, patients in need of care, and, at least, people who should never have been taken to an institution and the only reason that they were is the devious interest of another party in the community, whether or not that party be a spouse. We should not tolerate a position that would allow for such wrongful admissions to continue.
The existing procedure as laid down in the Mental Treatment Act, 1945, allows for the detention of a person as a temporary patient in a psychiatric institution  for up to six months on the application of a relative. It is easy to understand what might happen. It is not so long ago that geriatric hospitals were used for the detention of single mothers. Unmarried mothers were committed to institutions designed for another purpose. It was a mere graduation from the era of the workhouse. Unmarried mothers were confined at the institutions, they had their babies at those institutions, the babies were later adopted but the mothers had to stay and scrub the floors at the hospitals unless their relatives requested that they be allowed out. Such requests were never made in the case of many of those women. That is the society that we often call Christian. It is a society that often likes to sweep problems under the carpet, the same society that has left in psychiatric hospitals thousands of mentally handicapped people who should never have been committed to such hospitals in the first place. It happened merely because parents or relatives considered that psychiatric hospitals were the appropriate places to hide mentally handicapped people. There was no assessment procedure, relatives could commit people to an institution and they stayed there until someone asked for them to be released. Thank God we have moved away from those days and there is now some kind of assessment procedure. The Labour Party ask that that assessment procedure be amended to ensure that people receive humane treatment and are given humane attention.
Under current legislation a person can be deprived by their family of their basic freedom on the basis of the signature of a GP. As Deputy Fennell explained, the patient may not have been even seen by the GP or perhaps received only a cursory examination by the GP. After a cursory examination, an examination not defined in legislation, a doctor may sign a certificate authorising the committal of a person to a psychiatric institution. The application requires the signature of one GP only — two signatures are required if a private patient is involved, which practice in itself is discriminatory — before presentation to the chief medical officer of the institution.
Reforming legislation was passed by the Oireachtas in 1981 but, for the reasons outlined by the Minister, has not come into effect. The Labour Party are disappointed and upset that that has been the case. Even though the legislation may have had defects, it was an improvement on previous legislation and attempted to remedy some of the problems. I accept the Minister's statement that problems were identified.
Section 3 of Deputy Fennell's Bill provides that each admission requires the approval of two doctors. However, the Bill still does not clarify the examination procedure that would be required for involuntary admission. I believe that that weakness stems back to the 1945 legislation, which did not even define mental illness. One of the principal features of the Minister's Green Paper will be to seek a definition of mental illness. I look forward to that.
The Bill also proposes the establishment of a three member review board appointed by the Minister in each health board area. These reviews boards would comprise a solicitor, a doctor and a lay person; they would have the power to review a case and, if appropriate, discharge any patient who had been wrongfully detained in a psychiatric hospital for two years. This board will have to call witnesses and consider relevant papers and reports and their decision may be appealed to the High Court. This is the procedure laid down in the Bill. The Labour Party believe that this body could play a very important role in ensuring that wrongful involuntary admissions will not continue in future.
The area of mental health treatment requires immediate action to be taken by the Government. We look forward to the publication of the Green Paper. It is essential to publish this as quickly as possible so that we can study and discuss its contents and ensure that mental health treatment will in future be administered in a humane and sensitive manner. We can achieve that together. This question is bigger than any political grouping and we are all agreed that a consensus in this area is needed.
Mr. Moynihan: I thank Deputy Fennell for raising this issue in the Dáil Chamber and I thank the Minister for his comprehensive reply indicating his knowledge and sincerity with regard to psychiatric treatment. All those who have been associated with psychiatric hospitals down through the years are conversant with the point being made by Deputy Fennell — that some people in mental institutions feel that they are being held unjustly. The complexity of mental illness is such that it requires intensive assessment. Deputy Fennell's proposal to establish a mental illness review body in each health board area would provide a safety valve and would be a consolation to people who feel they are being unjustly held. They would know that society in general was disposed towards doing justice to them.
From my long experience with psychiatric hospitals I know that people have been admitted to hospitals as a result of marriage breakdown, family breakdown, a drop in property values, etc., and have become institutionalised after a number of years. The nature of mental illness requires immense investigation to justify holding a person but the establishment of these mental treatment review bodies will give patients an avenue of appeal. The fact that a person could appeal would demonstrate that we are conscious of patient rights.
 The Minister gave a very interesting resumé of his intentions and I subscribe to them totally. He said that in 1984 there were 11,600 patients in psychiatric hospitals and that that number has been reduced to 7,800. When the mental treatment Act was introduced there were 19,000 or 20,000 institutionalised patients in psychiatric hospitals. The practice then was to continue to build new accommodation and new structures to contain these people. Shortly after the 1945 Act, fortunately, therapeutic treatment was introduced and health boards and hospital management committees decided that the time had come for change. They discontinued building and looked for the latest in the therapeutic and rehabilitative fields.
The number of psychiatric patients who are institutionalised now is a small proportion of those who were institutionalised 40 or 50 years ago. However, much remains to be done in terms of education, and in terms of involving relatives and the wider community. I can recall a time when not 10 per cent of psychiatric patients were ever visited by relatives. Were it not for women's groups and the Society of St. Vincent de Paul who visited them once a week relatives would not have been convinced that these were human beings capable of conversing, of being entertained, and that they were not dangerous. As a result of initiating visits to the psychiatric hospitals many patients were subsequently rehabilitated and were able to go back into the community.
However, there is still a small proportion of people who are involuntarily committed to psychiatric hospitals who feel that they are being wrongfully detained. The Minister must concentrate on this area. I strongly urge him to take on board the proposal made by Deputy Fennell so that each health board area would have an appeals structure for psychiatric patients. The people on the appeals board should be of the highest calibre.
Only those who have dealt extensively with mental illness are fully aware of its  complexities. Investigation of an alleged case of wrongful detention requires deep and careful thought. The setting up of such boards may not satisfy all the people involved but it will at least demonstrate that the State has the interests of psychiatric patients at heart. That is the kernal of Deputy Fennell's case, one of concern to those associated with hospitals since their foundation. This concern will continue until such time as a structure is established to ensure that those people will have some redress if they have been unjustly detained and will be given an honest, appropriate decision.
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