3. Deputy James Browne asked the Minister for Health if he is satisfied with the level of mental health supports in place for persons with eating disorders; and if he will make a statement on the matter. (Question 6587/18 asked on 08 Feb 2018)

Minister of State at the Department of Health (Deputy Jim Daly): An individual who has concerns about eating disorders should attend his or her general practitioner, GP, in the first instance for primary care screening assessment and examination. The GP may then make recommendations, which may include referral to the secondary care mental health services for full eating disorder assessment.

Nationally, outpatient mental health services for adults presenting with eating disorders are provided by the general adult mental health teams. Similarly, children and adolescents with eating disorders are treated by the child and adolescent mental health service, CAMHS, teams. Specialist training in the treatment of eating disorders has been provided to clinicians within those teams as part of the national clinical programme in eating disorders.

Although most people with eating disorders do not require inpatient care, where an individual’s needs are more acute, inpatient admission may be required following the recommendation of the consultant psychiatrist or physician. When the risk is primarily physical and the person is in need of physical safety monitoring while re-feeding, admission will be to a HSE acute hospital under the care of a physician or paediatrician. Currently, there are specialist eating disorder services for adults, including inpatient bed provision, at St. Vincent’s University Hospital in Dublin, and for children and young people at Linn Dara services also in Dublin.

The HSE is currently developing a clinical programme in eating disorders. The HSE recognises that, although eating disorders are managed and treated by existing mental health services, these services may need support, particularly with high risk, severe and complex presentations. The clinical programme will help to develop greater capacity to manage people with eating disorders in the community to reduce the likelihood of acute hospital treatment.

As part of this programme, a collaborative model of care was formally launched in January 2018. This includes a stepped model of care delivery, a specialist training programme for existing outpatient mental health services, a new dedicated national eating disorder network, specialised inpatient eating disorder programmes within key existing psychiatric units nationally, and additional levels of care provided by the dedicated eating disorder network teams.

When this new collaborative model of care is implemented, there will be a national network of specialist eating disorder community team-based services and access to an enhanced level of special treatment beds. New clinical posts are being developed as part of this clinical programme. Recruitment for these posts will be advanced in 2018.

Deputy James Browne: The Minister of State set out a wonderful theory of what is meant to happen in mental health services where one can go to a GP and be referred on to CAMHS. However, the waiting lists to see a psychiatrist, psychologist or dietician in CAMHS in some areas are so bad, the service may as well not exist. The Minister of State referred to Linn Dara. It was shut down for several months last year because of staffing problems. I read the new recommendations for the stepped model of care delivery. While it reads fantastically, where will the Government get the staff for it? The Minister of State spoke about providing more mental health teams when the majority are underpopulated, some significantly so. Under the current model, there are 500 mental health nursing vacancies. From where will we fill those? Right now, 867 staff are eligible to retire and a further 885 will be eligible to retire within the next five years.

Plans and theories are great but, in practice, people are not getting the help they need with eating disorders. The rate of eating disorders is exploding. Practical solutions are needed.

Deputy Jim Daly: I accept what the Deputy is saying. Of our population, 5% will suffer from eating disorders. That is a large cohort. Anorexia nervosa has the highest mortality rate of any mental health issue, with a figure of 10% attributed to it.

The Deputy referred to staffing challenges. I am acutely aware of them. More than 2,000 posts in mental health services have been approved since 2012, but we have only been able to fill 1,300 of those. It is not a question of resources or money. The Government can only control so many factors. We must examine a new way of working. For that reason, I have asked the HSE to explore the avenue of teletechnology and telepsych, through which we can deliver mental health services online and in new ways. A consultant psychiatrist does not need to go to every crossroads and spend half the day travelling. Mental health is one of those areas in which we can be imaginative and more creative. We can examine ways of doing that. Among others, this is one of the initiatives that I am pursuing with the HSE to try to deal with the recruitment issue. I am confident that we will make progress.

I understand that there is pressure regarding the child and adolescent mental health services, CAMHS, waiting teams, but 114 assistant psychologists have been recruited. We must introduce a lower level of intervention. Not everyone who attends a GP with a mental health issue needs to be referred to a consultant psychiatrist. That has been the practice for years, but it is not necessary. We are in the process of building a lower level of intervention that will deal with many of these issues.

Deputy James Browne: Some 34% of mental health nurses are either eligible to retire now or within five years. By last August, 93 additional mental health nursing posts were filled. The issue is not being tackled. There are consistent criticisms from judges, in particular High Court judges. Anyone with a serious eating disorder is being made to travel to the UK, which has a further impact on people’s mental health issues. Families must travel over just to see them. The President of the High Court, Mr. Justice Peter Kelly, has highlighted an oncoming issue arising from Brexit. All of the enforcement of children getting treatment in the UK - there must be two enforcement orders, one from the Irish High Court and a complementary one in the UK - is implemented under EU regulations and legislation, which could fall away. It will be a major crisis. As Mr. Justice Kelly pointed out, this issue is growing so quickly that it must now be financially, if not morally, viable - it was always moral - to provide these services in this country. We cannot keep exporting the treatment of vulnerable people to the UK. They need their treatments to be available in this country.

Deputy Jim Daly: If we enhance community supports and services as well as increase and make more widely available lower level supports, we can prevent many of these cases escalating to the acute level. For too long, too much of the debate and focus has been on the extreme end of mental health. We need to build a community base, give assistant psychologists and therapists an increased role and deal with these issues as they emerge rather than after they have moved to being acute. Putting all of the focus on the acute end and building with that in mind is not the solution. We must reorient our direction and planning towards community supports and community teams, which is the policy that we are pursuing.

Acting Chairman (Deputy Eugene Murphy): Before we move to Question No. 4, there are six and a half minutes for each question - 30 seconds for a Deputy to introduce, two minutes for a Minister to reply and then four minutes overall for a supplementary discussion between the Minister and the Deputy. While I was in the Chair yesterday, I allowed a run-over on a number of questions, which meant that, although we should have been taking at least 13 or 14 questions, we took two fewer. In fairness to Deputies’ colleagues, who often sit in the Chamber for quite a while only to not be able to have their questions answered, I appeal to everyone to obey these rules as best as possible. I never like to inhibit debate because doing that would not be a good thing, but if Members remember the time slots, I will be fair to everyone.