COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
18 October 2007
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Mr John McCallister
Ms Carál Ní Chuilín
Ms Sue Ramsey
Dr Philip McGarry )
Dr Maria O’Kane ) Royal College of Psychiatrists
Dr Peter Gallagher )
Anne ) Mater Hospital service user
The Chairperson (Mrs I Robinson):
I welcome the representatives of the Royal College of Psychiatrists to this formal evidence session, which forms part of the Committee’s inquiry into the prevention of suicide and self-harm. I refer members to the college’s written submission to the Committee. The Royal College of Psychiatrists representatives are: Dr Philip McGarry, consultant psychiatrist; Dr Maria O’Kane, chairperson of the Northern Ireland faculty of psychotherapy; Dr Peter Gallagher, chairperson of the Northern Ireland child and adolescent faculty; and Anne, a Mater Hospital service user.
Witnesses, you are all very welcome. We have about an hour; and we look forward to hearing what you have to say.
Dr Philip McGarry (Royal College of Psychiatrists):
We thank the Committee for inviting us to speak. We are grateful for the opportunity. We have sent a written submission to the Committee; I will talk about that briefly, and then I will ask Anne to talk about some of her experiences, as someone who has been involved with our service.
The Royal College of Psychiatrists of Great Britain and Ireland was founded in 1859, and it is an all-island and all-archipelago body. It long predates partition. It represents psychiatrists in Britain and in Ireland.
The Royal College of Psychiatrists is responsible for the supervision, training and accreditation of psychiatrists, and for providing guidelines and advice regarding treatment, care and prevention of mental disorders. Approximately 230 members of our college lead multi-disciplinary teams throughout Northern Ireland. Psychiatric care is delivered through a multi-disciplinary team, which is led by a consultant psychiatrist. Nurses, social workers, occupational therapists and psychologists, among others, work together in that team. We work on a team basis.
Throughout Northern Ireland, each locality has a consultant-led team that provides a service. Psychiatrists work day in, day out, with large numbers of patients. Every time we see a patient, part of the assessment involves consideration of the potential risk of suicide. Our junior psychiatrists learn about that in their first week of psychiatry. We must address the issue of suicidal risk every time we see a patient.
Suicide itself is not an illness or a condition, such as depression or schizophrenia — it is an act that can occur as an outworking of various factors. Suicide may be closely related to major mental illness, such as schizophrenia, manic depressive illness or severe depression. Often, it is associated with factors such as the use of alcohol or drugs, severe social difficulties, personality factors and elements that are less immediately remediable by pure medical intervention. There is also a broader societal background. For example, America has a high suicide rate, which could be dramatically reduced overnight by gun-control laws. If America wants to reduce its suicide rate, more psychiatrists should be employed, and gun control laws introduced. That would have a dramatic effect on suicide and homicide. It is a complex subject.
We have identified three key areas in our document that we would like to raise today, on which I shall welcome members’ questions. The first area deals with those who have engaged in self-harm. Our report states that, each year, approximately one person in 10,000 will take their own life. That is a standard figure. People who have been admitted to hospital, having harmed themselves, are at a one-in-100 risk over the following year. In other words, the risk of suicide is upped by a factor of 100 among those who have self-harmed. Therefore, if we specifically target those who have harmed themselves, which is a high-risk group, we could do a lot of good. The National Institute for Health and Clinical Excellence (NICE) guidelines of 2004 recommended that we improve the services that we offer to people in that situation.
For the past two or three years, the Royal College of Psychiatrists has been working on a major audit project with our colleagues in the Royal College of Nursing, the Faculty of Accident and Emergency Medicine, and the Ambulance Service. We are improving on what we can do, but we are not doing enough, because there are insufficient resources to provide a full assessment and follow-up for those who have harmed themselves.
Last year, I spoke to one of the top UK gurus in the field, Dr Navneet Kapur from the Manchester suicide centre. I asked him what one thing he would do to tackle suicide, and he said that he would consider what he could do for patients who have harmed themselves. We could do better than we are presently. In Northern Ireland, we are trying hard, and members will hear about the project at the Mater Hospital shortly.
We are also concerned about the fact that 10% of those who self-harm and attend hospital departments are adolescents, and we do not have the appropriate follow-up or back-up services there. That is an ongoing problem. Members will be aware of the difficulties with recruitment in child and adolescent psychiatry, but we could do a lot better. Therefore, there should be a major focus on those who have harmed themselves.
At the Mater Hospital, there has been departmental funding for a team until the end of March 2008. That team is led by Dr O’Kane, and it does a lot of work with people who have harmed themselves and provides follow up for a short period afterwards. Those who have harmed themselves repeatedly have been given active, intensive support, which is producing encouraging results. The team is only a temporary project — it is not permanent yet — but it is producing work that is of a very high standard.
The second area that I would like to mention is the need for more talking therapies or psychotherapy. Psychotherapy relieves emotional distress through the use of a talking technique.
It is a mentoring therapy.
That is part of it. Psychotherapy moves beyond counselling in that it is very much about the therapist’s trying to understand the individual and get to the root of the problem, and enabling a person to use that analysis to help themselves. Historically, the provision of psychotherapeutic services in Northern Ireland has not been as good as it should have been. Doctors now see many patients with very complex problems, and Dr Deeny will be well aware of that from his own experience.
It is relatively rare for patients to have straightforward depression. Most patients whom I see will have a depressive illness, but other factors will also be involved — their family or home situation, work issues, educational and employment issues, debt, alcohol, and so on. Many factors may contribute to the problem, and it takes a great deal of time to work on those.
However, the evidence shows that, if the effort is put in, good results can be achieved. We are aware of the Minister’s announcement last week about funding for psychotherapy, and we would welcome the Committee’s support in sending a loud and clear message to the Minister that more psychotherapy services are needed in Northern Ireland. That would have an impact on the problems faced by some of our self-harm patients.
The third matter that I wish to highlight is alcohol. Most psychiatrists who see self-harming patients in general hospitals would reckon that, in over 50% of cases, alcohol has been taken. In many of those cases, had those individuals not taken alcohol, they may well have not harmed themselves. Obviously, that raises the issue of alcohol addiction services, which we believe are pretty good in Northern Ireland. They could be better resourced, but the community addiction teams do an excellent job. Major public health issues arise in that area, which we, as a society, must examine.
There are also political considerations, including issues such as the price of alcohol, the availability of alcohol, sponsorship of sports by drinks companies — some of us find it difficult to understand why such sponsorship is accepted by sporting organisations — and advertising. Those issues must be addressed on a political level. We have a binge-drinking culture here; it is considered quite acceptable. Those issues are not simple; they are complex, but they must be addressed.
The problem is underpinned by certain factors. Our society has had its difficulties, and suicide rates are higher in societies in which there are high levels of unemployment and social deprivation. There is no doubt that our history of violence has left a legacy, and that is understandable. However, we are now moving on from that legacy, and that is very encouraging.
We must create a society that advocates respect for other people and for ourselves. If we do not respect other people, we will not respect ourselves. Suicide and homicide are two sides of the same coin. We must create a culture that promotes the understanding of others and respect for others and ourselves. That effort must involve everyone, not just psychiatrists, although we have a role to play. Community and voluntary groups, politicians, families and individuals all have a part to play too. Work must be carried out in schools and in the youth sector, and, as has been pointed out earlier, the Department of Health, Social Services and Public Safety and the Department of Education must work together to address this issue. The Department of the Environment must also be aware of the need to create a decent environment when building new housing.
In recent years, the media have been very helpful to us in their coverage of our anti-stigma campaign, Changing Minds. Much good work has been done to promote awareness of the importance of positive mental health — it is as important as physical health — and to promote awareness of the signs of mental ill-health that should prompt people to seek help.
However, media reports have also been unhelpful at times. We sound a note of caution about the potential, on some occasions, for the reporting of suicides to be counter-productive. I know that the Health Minister is considering the matter of working with the media, and we are also doing some work on that. In general, the media have been incredibly helpful in their coverage of work in the mental-health field, but it is important that they be careful to report suicide in a sensitive manner.
I would like to introduce Anne, who has used Dr O’Kane’s service in north Belfast. She would like to make a few comments.
Anne, you are very welcome.
Two years ago, I was sent to see a self-harm team because I was suffering from depression. At that stage, I was very low. I did not want to go to meet the team, and I did not want to be around my two children. As a mum, it is very difficult for me to admit that. With the help of the self-harm team and my GP, I have come out the other side. I have come a long way.
I am one of the lucky ones. I had cut my arms, and I do not do that any more. I received intense help through psychotherapy and through talking with the doctors and with my community psychiatric nurse (CPN). That has been really great. I would not have had that opportunity anywhere else.
Such help should be readily available for anyone who needs it. People benefit, and not just the person who self-harms, but the whole family. My family unit has changed: my kids are more relaxed, and I am more relaxed. I am getting married. I would not have been able to sit here and talk to you two years ago, and that in itself shows that I have come a long way. The service is beneficial to the whole of society; it should be there and it should stay there.
Thank you for inviting us. Psychiatrists work every day at a clinical level, seeing patients and trying to help. However, we also want to help with policies, and if we can be of any assistance to the Committee today or at any other time, we will be pleased to help.
Peter and Maria, do you wish to add anything before members ask questions?
Dr Peter Gallagher (Royal College of Psychiatrists):
It might be of more use if we responded to members’ questions.
Dr Maria O’Kane (Royal College of Psychiatrists):
Yes, we are happy to respond to members’ questions.
Thank you for that very interesting synopsis of the problems, and for telling us about your work. Dr Paul Miller, one of your colleagues from the Mater Hospital, came before the Committee in July. He made a very telling point when he said that suicide is a permanent solution to a temporary problem. That comment has resonated with me ever since. We must reach out to people before they get to that stage. Prevention is the key.
Your submission states:
“Of those who self harm, 1% are likely to complete suicide within the next year, an increase in risk of 100 times. This is clearly an easily identifiable group of people who are at risk and who can and should be offered thorough assessment and, if necessary, follow up.”
I take it that the reason that they are identifiable is because they present themselves.
Yes. Anyone who comes to an A&E department will be, and should be, well documented, and will be offered psychiatric follow-up. The problem is that, across Northern Ireland, the services in general hospitals have been poor, particularly at weekends. Some hospitals may have one liaison nurse who is excellent, but when she is on leave, off sick or off at weekends, there is very little help available. There may be an emergency junior doctor on call who is doing a lot of other things and does not have the time to do things as thoroughly as would be liked. That is an area for which extra resources should be found. That would not need to be massive extra resources, but it would be very worthwhile.
The Committee has been discussing this matter in great detail and has identified that a room should be set aside in every A&E department where a voluntary group — the Samaritans or some other group — could be there to settle someone until the appropriate clinician arrives and assesses the person to ascertain whether they need to be admitted or not. However, we are teasing out that issue, and I would be glad to hear your opinions on that.
I know from personal experience that there seems to be a rash of young girls who are self-harming. I am not just referring the Ulster Hospital, but it is in my constituency. When such girls went to that hospital, no one was available to assess them at weekends, and they were placed in a general ward, or perhaps a geriatric ward. That is not conducive to helping young people.
Dr O’Kane is running a pilot scheme at the Mater Hospital examining that type of work.
We have had to think about that matter. That issue has been raised through the college audit, which is being carried out at the minute through the Royal Victoria Hospital’s and the Mater Hospital’s A&E departments. Obviously, they are confined by space. We started by trying to identify a space within the A&E department where a person could be assessed quietly without fear of interruption, and with solid walls instead of curtains. Finding such a space is a challenge in itself. Those two A&E departments have worked very hard with us to try to achieve that. Things are far from perfect, but they are better than they were.
Our statistics show that 80% to 90% of people who require psychiatric care who present at A&E have taken an overdose. They may also have cut or burned themselves, or engaged in some other form of self-harm. Those people need some form of medical treatment. Having a room set aside would be helpful for some people, but the majority of the rest would probably need medical intervention, so we require access to the A&E area.
In the course of the audit, we visited various facilities throughout England. We found that those facilities attempted to provide a room for a family member to be present, but it was not as well organised as we would like. We were unable to find a perfect situation. Sometimes, those rooms were very isolated. If there was a bereaved family to be accommodated, or victims of a road-traffic accident, services had to be offered to them and the room was automatically taken over. That is a difficult target to achieve.
The idea of having someone to accompany and support a person who has self-harmed is a good one. We have been exploring that with the voluntary agencies, with which we work closely. As you know, there are three agencies in particular which operate in north and west Belfast: the West Belfast Self-Harm and Suicide Prevention Initiative; RAYS, which is based in the greater Shankill area; and the PIPS project, which is in north Belfast. When those groups are made aware of adults who present with problems, they will try to accompany them to an A&E department. That has worked extremely well.
We considered reintroducing the “pink ladies”, who were — famously — the ladies who brought tea to people who were waiting in A&E departments. Together with the voluntary agencies, we have begun to think about how we could use people who are trained to competent-helper level. That is being considered. However, inevitably, when one starts off with 100 people who are willing to train as competent helpers, one ends up with only a few who finish that training.
To support people who have a high level of distress when they present is difficult. People find such situations very distressing. One needs to be sure that the person who is offering support is sufficiently robust to do that adequately, rather than reinforce the sense of hopelessness and neglect that people who self-harm have.
That is a difficult balance to achieve. I believe that greater use of volunteers would be very helpful. There is a wealth of intelligent people with common sense, which could be tapped into. That is more important than a list of letters after one’s name. Many would jump at the opportunity to help young people. The Committee believes that that is a good way in which to proceed.
I meant to say Anne that I am delighted that you have come through to the other side. It is good to see and identify people who have come through the gamut of depression. There is hope at the other end. I am delighted to see you doing so well, and I wish you well on getting married.
Members may now ask questions.
Ms Ní Chuilín:
Well done, Anne. I wish you all the best — you have been on a journey. Good luck.
I live in north Belfast, and it disturbs me greatly that I am continually hearing stories of people going to A&E, having to wait for six and a half hours, and then having to leave, unattended. We all hear those stories, no matter what the hospital. That is very frustrating for staff. Everyone who has to deal with such situations is totally frustrated.
I have read your recommendation that there should be a rota of adolescent-mental-health professionals. It seems unlikely that that can be organised in the near future, given recruitment problems.
I had thought that things may have improved. We visited the home-treatment centre at the Mater Hospital, and I was really impressed. That is the way forward.
Groups such as PIPS and RAYS and others work at weekends. If their services are continued, if recruitment targets can be met, and if projects such as the home-treatment centre — or your own, Maria — are continued, they may be little rays of light for us.
The recruitment issue is particularly acute in child and adolescent psychiatry. Some argue that the home-treatment team and some of the new advanced teams are recruiting excellent staff and creating a deficiency of staff elsewhere in the system. As you know, there is a big shortage of nurses in Northern Ireland, which is a continuing problem. The point about recruitment and staffing in child and adolescent psychiatry is very important.
Dr P Gallagher:
The key issue, assuming that we regard mental health as a Cinderella service, and taking on board the Minister’s comments, is that we have 25% more mental-health difficulties in Northern Ireland, but 25% less funding allocated to child and adolescent-mental-health services. I use the term “mental health” in the broadest sense, not in the narrow specialist sense that implies mentation, which is just the way in which we think about something, and which influences the way in which we do things.
Notwithstanding that, Northern Ireland has a very high percentage of young people who have mental-health difficulties — between 20% and 40%. Northern Ireland has a higher percentage of people under 18 years of age — between 27% and 33% — in contrast to the UK, where that figure is about 21%. Between 2% and 5% of mental-health funding goes to the child and adolescent sector, so there is a huge gap between those figures and what is actually required. We know that our society is toxic to children’s development, and if we look at the way in which the media acknowledges the difficulties that surround the issue of self-harm, to injure oneself is now almost a cultural norm with which to define one’s distress.
There are many interventions that must be tried, but the key issue is resources, both human and financial, which must be yearly and sequential. There is no point in being handed a large amount of money tomorrow morning, because there will not be enough staff available to make use of it, particularly not in an accident and emergency department. Although it is helpful to have a mentoring process in an A&E department, children and young people have a tendency to only get one bite at the cherry. The person with whom they form a relationship, and the nature and quality of that relationship at the beginning, will determine whether they will come back to a specialist service to address some of the issues that have led them to take an overdose or self-injure.
That requires someone to be available in an A&E department because, if that is not the case, the young people will vote with their feet and not return. They will, however, keep coming back because, in a sense, self-injurious behaviour is the end stage of a distressing event. Despite the way in which it is portrayed by the media, no one who attempts to end his or her life as a solution to their difficulties does so lightly.
We must treat this problem with the gravity that it deserves and provide the interventions at the coal face. It would be most helpful to have on hand a trained mental-health worker who would assess those youngsters and begin to transfer them to specialist mental-health services. That service should be available in every A&E department, Monday to Sunday, 24 hours a day. That is a key intervention, and it can make a difference. Unless that happens, we will only be mopping up, because we are on the cusp of the way in which human beings define their distress.
It is important to have an aggressive advertising campaign about self-respect and, as Dr McGarry said earlier, about how society values the individual. Services should be available, and we should be our brother’s keeper, and, more importantly, we should become our brother’s saviour. Mentoring is valuable, but unless we have therapeutic endeavours that help people to give order and meaning to the difficulties that they are experiencing, and address their distress, they will just repeat the process.
Ms Ní Chuilín:
That is what is happening now.
Dr P Gallagher:
Mr T Gallagher:
I would like to thank the witnesses for their attendance and contributions. The scarcity of resources and trained personnel was mentioned. There is no doubt: it is clear that mental-health problems in society have increased markedly, and some of the relevant figures have been mentioned.
No one is going to wave a wand and deliver all the resources that are required to deal with this problem. Philip, you mentioned high-risk, vulnerable people who self-harm. Let us suppose that £12 million was made available; how would you like to see that amount distributed? Should that be spent on people who self-harm, or should only some of it be spent in that way, with the rest spent on therapies for other types of poor mental health?
A witness at one of the Committee’s previous meetings commented on problems of that nature, and took a strong view that the education system should be providing children with information about good mental health. What do you think of that?
I am not overly pessimistic; the services will not necessarily need a huge amount of money. The new trust system might help. I know from working in the Mater Hospital that, in Belfast, I was working with patients from six different trusts. Now there is one mental-health director, the situation is much better. Things are changing, which is good, and we can work more efficiently.
I have talked to suicide experts in England who believe that examination of the self-harm population is very important, as is meeting the NICE guidelines. If NICE says that a drug is recommended for treating a certain condition, we assume that people will get it. However, NICE recommends assessments for people who self-harm, but many people do not get them. That is unacceptable.
The solution need not be massively expensive. A few extra staff in Belfast could cover the Mater, Royal and City Hospitals. There could be one person in the hospital and one on call, if necessary. That would not require massive expenditure.
The trusts will need to refocus the way in which they work. Historically, general hospital staff felt that self-harm came under the remit of psychiatry, rather than surgery or medicine, and that it had nothing to do with them. The community trusts felt that it came under the acute hospitals’ remit, so it fell between stools. The Royal Victoria Hospital has no liaison psychiatrist, for example. The new system offers an opportunity for joined-up thinking.
We do not need a massive amount of money, and it is important to make that clear. However, we need someone to say that providing the service is worth doing, and to work out how to do that efficiently. That does not require many personnel; just a sufficient number of people who are linked with the rest of the services. That is not to say that an adolescent might be seen by Dr Gallagher the next day, but he or she could be put in touch with a person who could decide whether the case was urgent and ensure that the patient is seen that day, or whether an appointment could wait for two weeks. Joined-up thinking is more important than massive amounts of money.
Mr T Gallagher:
What about the education programme?
Peter will speak about schools, and what can be done there.
Dr P Gallagher:
There are several requirements. The first is a media campaign that promotes mental health. Secondly, there should be a link person, in case anything happens. That will not cost an enormous amount of money, because he or she would be required only for critical periods. For example, someone could work from 9.00 am to 5.00 pm during the week and at certain hours at the weekends.
Thirdly, support in the school system is important. For example, a young person might know of someone who is vulnerable, but he or she might have the idea that it is wrong to intrude. We need to emphasise that people are connected; we are social beings, and, consequently, we cannot avoid relating to one another. We must connect with, and care about, one another. The availability of some type of counselling service in the school system would be very helpful. Funding could be made available for more specialist services, as they are needed.
Your question is apposite. We must think about what each bit of the service could do if it had a certain amount of money that might alleviate the problems, instead of seeing the issue as just one person’s problem.
If each community, hospital, school, education, adult college and mental-health system were to join together, do one bit and ask what the next person could do, there would be less likelihood of reading in the papers about another suicide.
Thank you very much for your presentation. Anne, your story really made me feel good, and you reminded me of a patient of my own. It just shows that you can get out of hell, and it is wonderful that not only do you feel good having done that, but you make others feel good.
One of my questions has perhaps been touched on. The child and adolescent recruitment problem was mentioned. We have a very good professional in Omagh, but she is on her own and there is a long waiting list, although we can ring her directly. Is there a lack of interest in child and adolescent health? I hope not.
Dr P Gallagher:
It is partly a lack of resources, not a lack of interest. To put that in context: in Northern Ireland, between 2% and 3% of the total mental-health budget is spent on child and adolescent mental-health services; across the water it is between 10% and 15% for the rest of the UK. If you assume that the prevalence rates for adult mental-health difficulties are exactly the same as for child and adolescent mental health — which they are — and that between 27% and 31% of Northern Ireland’s population is under 18 years old, then the budget should be higher — more like 25% to 27%. Assuming that that will not happen tomorrow morning, planned development is needed. Not only psychiatrists are needed, but social workers, mental-health nurses, clinical-nurse specialists and psychologists, because we are an integrated system.
This Committee could perhaps persuade the Department to begin to plan sequentially, to allow for the feast or famine that tends to happen in systems, when money cannot be used because the people are not there. If every organisation were to increase its staff by a factor of 20%, year-on-year over a two-, three-, four- or five-year period, it would be possible to absorb and train people, and therefore expand part of the capacity of that service. That needs to happen; moreover, it is part of what the Bamford Review recommended. It should operate sooner rather than later.
Thank you, Philip, for pointing out something that the public needs to be told. I will never forget the young fellow that I found hanging from the rafters. None of us knew anything about him, and no one knew that he was mentally ill. The whole suicide issue is multi-factorial, and you mentioned personality difficulties, inter-personal and social.
Post-natal depression concerns me. A young mother came in to see me last week with post-natal depression, and no woman should focus on that when she has just had a baby. I came across a woman who had suffered with depression for nine years and, after GP and consultant help, it was discovered that she had prolonged post-natal depression.
One area where the media has helped is in demystifying suicide, although I know it can make a mess of things and some of the copy-cat suicides can be put down to it. In America people have perhaps gone to the other extreme with openness; however, people talk about mental health, which is a really good thing.
We need to get to our young people, perhaps in school, and particularly to young men who, because of the whole macho image thing, will not talk about their problems. With regard to psychotherapy, your handout mentioned that psychiatrists and GPs are frustrated, and that could not be more correct. A third of our consultations are on mental health and, although the medication we prescribe may help, we know that it is not the answer. Psychotherapy is the answer.
In the past week I had a patient with problems which — in my opinion — did not require a drug solution. I latched on to the fact that she might have some marital problems and that she might need psychotherapy. I gave her telephone numbers for Relate and Accord because they could provide her with some sort of therapy. Had it not been for the link with a marital problem — and perhaps I was jumping at that — there was no other facility to which I could have referred the woman. We have cognitive behavioural therapy at an excellent facility in Omagh, and, I am sure, there are others in Northern Ireland.
What do we need? Do we need more funding? It is great to hear from the professionals in the psychiatric mental-health area. I am sure that you will get the backing of the Committee, which has talked about the issue of mental-health and is committed to it. Do we need to put funding into psychotherapy so that I, or any other GP, can say that that option is available? We see so many people with mental-health illnesses who do not even get as far as seeing a psychiatrist.
It came through that you have a special expertise on the matter.
I will address two issues before answering your question on psychotherapy. Fifty per cent of the people that we see are parents with very small children. I accept Peter’s point about the need for child-and-adolescent-service development. However, I am more mindful of the fact that a lot of our patients are parents, as Anne pointed out. That is terribly important as regards improving the environment in the home. That is why we feel that our work is important.
One of the difficulties with psychotherapies is that there is a huge level of interest across psychiatric services in the development of talking therapies. As you know, there has been an expansion in CBT; however, there has been less of an expansion in the other psychotherapies. The difficulty is that one must be able to think in order to do CBT, because it is a cognitive therapy. A lot of the people with whom we are in contact are not able to think, because they are so overwhelmed by what is presented to them that, sometimes, we need to start at a lower baseline and then work our way up. We are conscious that, in mental-health services, accessing CBT is a little easier than accessing some of the other psychotherapies. Nevertheless, we see many people respond well, for example, to family therapy and individual interpersonal therapy. It is not a case of one therapy fitting all; there is a whole gamut of therapies, and access must be expanded.
There are quite a lot of people who are trained in the mental-health workforce. However, the difficulty for them is that they are not in jobs where they can deliver that, day-on-day, in the way that would be preferred. For example, although a significant proportion of our nursing staff have training in family therapy and in some of the other therapies, and use those skills to enhance the job that they do, they cannot fully concentrate those skills in that area because that is not the way in which they are employed. Recognition of a variety of therapies that will allow people to progress into posts for which they have been trained must be encouraged — and not only in the Health Service. Overall, there must be support for the importance of psychotherapy in the NHS.
Thank you for your presentation; it was helpful to the Committee. I was particularly interested in hearing about funding 24-hour cover in A&E; that is critical in improving that service. I was also interested in the profile of service-users on the last page of your submission to the Committee, particularly in drug and alcohol abuse, which seems to be a big factor. Does Northern Ireland need a stand-alone centre to deal with drug and alcohol abuse? We do not have that type of facility, and patients have to go to England or Scotland for treatment. Would it be helpful to have such a unit?
The services for alcohol and drug misuse are reasonably well-developed in Northern Ireland. There tends to be a good working partnership between the voluntary and statutory agencies. We see many people who use alcohol and drugs, not because it is their primary addiction but as a means of alleviating distress. A joined-up approach would be very helpful in providing a good outcome for a person who presents because of self-harming and the use of alcohol and drugs. People see trained mental-health practitioners and others in a position to help, but it must be recognised that those services need to work together, rather than having people attend one place for drug and alcohol problems and another for mental-health problems. There must be better working practices across the agencies.
The difficulty has been that the drug and alcohol services are reasonably well developed, but other services less so. Inevitably, therefore, people who avail of services to deal with drug and alcohol problems probably receive some help to manage those. Alcohol and drug practitioners do good work, but it is not possible for them to deal with people’s underlying distress and their situation as a whole, because they do not have that expertise.
The agencies need to come together to a greater extent.
That was an interesting presentation. Anne, it was courageous of you to come here and share your story, and I am glad that you were fit to do so. It is important to send out the message that people who have gone through particularly low periods in their lives can come through. You have my every good wish for your forthcoming wedding.
Peter, you made a point about funding. Throughout so much of Government, the way that some of the budgets are allocated can mean a feast or a famine. We must consider a better system of securing streams of funding, because the training of people to deliver mental-health services cannot be turned on and off like lights. It takes a long time before they are fully trained and in place. Will you perhaps comment further on that?
Some colleagues mentioned the mental-health agenda for schools and education. Have you any thoughts on, for example, first aid for mental health in the workplace too? When considering the overall health-promotion strategy, what areas of the mental-health agenda should we include?
Philip, you and Alex mentioned alcohol and drug issues. Have you any further thoughts on any recommendations that we should make? What are the key areas when considering alcohol restriction? What did you think of the statement of the Chief Constable of North Wales, when he advocated the legalisation of drugs? I understand that you may not wish to go down that road, but it is part of the overall debate on an alcohol and drugs strategy.
The Chair mentioned that the community and voluntary sector plays a vital role in so many ways, and, as Maria said, it is important that it takes an important role in tackling drug and alcohol addiction. What more can we do to stop it getting to the stage that it is a problem? How do we address the binge-drinking culture? Is it all down to the price of alcohol?
In the workplace, a great deal of work has been done using ASIST, which is applied suicide intervention skills training, and that started in Canada, 20 years ago. I was involved in taking a course with two nurses and someone from PIPS. It has been rolled out to over half a million people worldwide. The two-day course is geared towards people such as youth leaders, community workers, police officers, fire services, and so forth. It educates people on how to identify any early warning signs shown by an individual and how to deal with that person. That training continues, and the voluntary and statutory sectors are doing good work rolling it out.
Ms Ní Chuilín:
Is that ASIST?
How many people in Northern Ireland have been trained?
There has been fairly extensive training in Northern Ireland in which PIPS, some of the nurses from the Mater Hospital and various others have been active. ASIST is good and continues to develop. It is an example of a great joint initiative that informs people in positions of leadership, the local communities and the clergy how to deal with that single issue. It is a case of the more joint initiatives, the better.
Alcohol is a bigger factor in suicide than drugs. I will not take the line of the Chief Constable of North Wales in this forum. Binge drinking is a cultural matter, which would remain even if opening hours and advertising were restricted. In France, where there are long opening hours, the culture of going out and getting boozed-up does not exist. There is a weekend-binge culture in Northern Ireland. Kevin Malone, who is a professor of psychiatry in Dublin, has carried out examinations of young people’s brains. Evidence from post-mortem studies shows that alcohol affects cerebral biochemistry: the levels of serotonin and noradrenalin. Professor Malone suggests that young people are more vulnerable to the biochemical effects of alcohol than older people. At present, there is a big disparity between the number of young men and women who commit suicide. The potential danger of the binge-drinking culture is that increased drinking among young women may result in more of them taking their own lives. A wide spectrum of measures must be taken, involving advertising, sponsorship, and so on. There should be a public debate on the matter. It is everyone’s responsibility.
As Dr McGarry has mentioned, the drinking culture in continental Europe tends to be much more family oriented.
People will have a glass of wine followed by a coffee. Then they will go home.
That is interesting. We can forget about views on drugs.
For your information, Dr McGarry, Professor Malone has sent the Committee a submission.
Ms S Ramsey:
Like other members, I thank Dr McGarry for his presentation. Anne, I too wish you well. You have made a wedding present of this matter. It is nice to see something positive come out of those horrible statistics.
The Committee is conducting an inquiry into suicide and self-harm. I want to try to tease out some information from Dr McGarry’s paper. The Committee would have no difficulty in being critical of the Department. I hope that at the outcome of the inquiry, the Committee will be able to make recommendations.
The paper identifies key areas that the Royal College of Psychiatrists believes are essential to tackle the problem of suicide, three of which are highlighted. Has the Department agreed with those recommendations? If so, what has it done? If not, why not?
I have several questions. Should I ask them all at once, Chairperson, or one after another?
Perhaps wait and ask them one by one.
Those issues have been raised with the Department in different contexts over the years. There is a yearly speciality advisory committee, where the profession meets with senior officials from the Department of Health. The Department is aware of such issues as liaison psychiatry in general hospitals, and psychotherapy over the years. The college has been engaged in consultation processes as far back as it has been able to do so. At present, I cannot say what the Health Department’s priorities are or what its thinking is. I hope that the Committee will help to put further pressure on the Department. The college will support it in doing so.
Ms S Ramsey:
Page 2 of the submission states that:
“The NICE Guidelines (2004) demand that every patient is given a full psychosocial assessment after self-harm.”
I am concerned about whether that happens because I am aware of several incidents in which A&E doctors have not necessarily said whether patients have self-harmed and have told them to go home and give their heads a shake.
The answer is no. However, the situation is improving. Dr O’Kane can explain her project.
One issue that was identified in the audit that we carried out was that as low a percentage as 30% of such patients who attended A&E at any given time were given a psychosocial assessment. That was one of the statistics that compelled us to request funding to set up a team that could tackle that. At present, the audit is mid-cycle. Our informal audit has picked up that statistics in the Mater Hospital and the Royal Hospitals have probably gone up to 60% or 70%. However, the limiting factor is access to staff.
One of the things pointed out earlier was that if a person has a particularly long time to wait, he or she will leave. We have been trying to improve that by contacting the person after he or she has left, if we are aware of that, with regard to social assessment or engagement. I am involved with that function of the self-harm team. However, we are concerned about the fact that things are not done as comprehensively as they could be, and that people slip through the net.
Ms S Ramsey:
Families are concerned about the lack of GP uptake and training, so there might be an issue with the ASIST programme.
GPs on the ASIST programme have said that the training is helpful to them when dealing with a suicidal person. However, they are also interested in the next level of training — the STORM project — which, although there are various other training schemes, is recommended by the Department in its high-risk-management guidelines. We have started discussions with the Health Promotion Agency and the Beeches, which is the nurse-training centre for the Belfast and south-east trusts, in an effort to try to spread the training out and make it available to GPs and other health professionals. Several staff are trained to deliver STORM, and we are trying to train more, so that there will be more hope of rolling it out and sustaining it.
ASIST is an excellent programme for the voluntary sector. Health professionals have told us that it is extremely good, but that they would like the next stage. One of the reasons that GPs find ASIST difficult to take up is that, like everything else, there are competing needs, including diabetes, epilepsy care, and so on.
Ms S Ramsey:
You said in your paper that you welcome the £3 million funding that has been made available, etc. However, groups in the community and voluntary sector have problems with planning ahead, because of the issue of long-term funding. I do not ask you to get involved in a political issue but, in relation to children and young people and the lack of services in adolescent mental health, there is speculation that the Children’s Fund and children’s services will be hit big time in the Budget. Will that set us back further?
On a positive note, you referred to working in schools. At a previous Committee meeting we made a suggestion to the Minister about the ministerial task force. The Department of Education is involved, but there was no involvement by the Department for Employment and Learning. The Minister agreed with that and said that he would take it on board.
You mentioned the lack of communication. How can that be dealt with? My final point relates to the figures showing the profile of the service users, and Alex and John have already referred to those. It is useful to have a profile of the service users. Are there any plans to be proactive on the figures? They show that 23% of those who self-harm had been in care as children. Are there any future plans to target people in a care setting? Are we tying in with Sure Start, or organisations that deal with teenage pregnancies, so that we do not always react to issues? We want to be proactive.
We welcome the funding made available and the task force. I was on the task force and it has a multi-agency, multi-factorial approach, and it is important that that is kept up. There are 19 trusts, and I was not clear what the channels were for me to know what was going on in the community and vice versa. We need more funding for the community and probably more for ourselves, working together. As Maria said, it works well with PIPS and the other organisations in north and west Belfast. There is work that we are best-placed to do, and work that the voluntary sector is best-placed to do, and it is good to know what each is doing. I hope that the situation will improve when we are down to five new trusts. It is important, and I believe that the new trust system will benefit that.
We do not think that service users have been profiled before in Northern Ireland; we were certainly not aware of it. We have been able to look retrospectively at the profiles of patients who come to us.
I have spoken about the issue to Bernie McNally, who is our director of children’s services for the Belfast Health and Social Care Trust. She is proactive in such services. She is the chairperson of the audit, and she was our original director of mental-health services. She has given some thought to developing children’s services and to the issue of patients as parents and the impact that that has on families. There is no formal process in place to try to use that information to help development in other areas.
Dr P Gallagher:
We need to target money to the appropriate services. Between 65% and 95% of children who have been in care will have a severe mental-health difficulty, but they are limited in the services that are provided for them. That causes long-term problems in their education, their socialisation and their future development. Again, the difficulty is that child and adolescent mental-health services compete for little, and they are at the bottom; therefore, it is similar to trying to rearrange the deckchairs on the Titanic. That is all that is going on, unless a sequential fund is provided for those services, but it is a huge area. Lack of funding can lead to further problems in the future, because those children and adolescents will continue to be users of such services, and we know that early intervention has an effect.
You are all very welcome. The Committee is trying to be as well informed it can, so that it can be as helpful as possible, particularly with the Bamford Review. It is seen as an opportunity. How much input did the Royal College of Psychiatrists have? Maria talked about training, but the Bamford Review refers to working smarter, and better team-working, and it sets out a vision. How involved has the college been in setting out that vision, putting it in place and making it work? You talked about training and anticipating future needs, about prevention and about all the societal reasons, such as lack of respect. Peter talked about the continuum. When you do something good, how is that mainstreamed so that it simply forms part of what everyone is doing? You mentioned the talking therapy, which makes sense, as it is always helpful to talk things through with someone. How much of the funding, if any, will be skewed towards adolescent services, since that is where there is a great need?
You talked about young parents. Many adolescents are also young parents, which is a huge responsibility for a young person to cope with. Then there is alcohol, which is a huge issue, and is probably the biggest public-health challenge that we face, particularly now that we have tackled smoking to some extent. It is probably the next-biggest issue.
How much influence and input did the Royal College of Psychiatry have in the Bamford Review? I believe in prevention rather than in picking up the pieces. How much of the budget will go on underlying causes and prevention? They are huge societal issues, but we will always be picking up the pieces unless there is more focus on particular services. How much of a mental health budget goes towards the prevention and the underlying causes, particularly of self-harm?
Many of our members were involved in the Bamford Review. It is a massive review, so many folks were involved. The college supports the product of Bamford, but it is a massive document with many recommendations, and, from what we hear, the funding is not that marvellous. Although we are here on behalf of the college to talk about suicide, we cannot suggest that severe schizophrenia, for example, should be ignored in the large mental hospitals.
We do not feel that what we are stressing would necessarily cost a massive amount of money — I want to make that clear. It is absolutely crucial that we work a bit smarter with the voluntary sector, and them with us.
It seems that what you are describing is part of a snapshot of what needs to be done, and where that fits in with the overall strategy.
Dr P Gallagher:
Proper allocation of funding is required in order to set clear projects for children and young people. The problem that all of us face is that most of the funding tends to occur on a non-recurrent basis, and it is possible for our achievements get lost because of competing demands. Therefore, a model is required in the Department to audit what funding has been used for, and then, if the evidence base is valid, to ensure that recovery can follow on from that.
You are talking about Maria’s example — establishing good models, then mainstreaming them.
Dr P Gallagher:
The Bamford Review made a lot of recommendations. To tackle death by suicide, we need to begin to target particular areas, consider funding for those areas and monitor the outcomes. It would then become a little easier to bring those plans together. That is the key for the future.
Today’s discussions have covered a lot of ground. There is no doubt that prevention is the key to the whole issue. However, no matter how many preventative steps are in place, this difficulty is still going to exist because of the current culture in society.
After someone has had problems and has received treatment, it is the follow-up programmes that become important when that person is back in the community. What types of follow-up programmes exist, for instance, for visiting a person at home on a regular basis after they are released? If that does not happen, more problems will be created due to the stigma that is attached to this issue.
The home-treatment team manage people at home rather than having them go into hospital — that is the best model of psychiatry. That is not always possible, but it is more so now than it was five or 10 years ago. Preventing admission to hospital through intensive support at home with up to four visits a day is particularly effective in some cases. That model has been rolled out across Northern Ireland, and it is very good.
When someone is admitted to a psychiatric hospital, we have a duty to ensure that the planning for what happens after the patient is discharged is of the highest quality. That requires us to work with the multi-disciplinary team in the community, including the psychiatrist, the CPN, or the lead person in the follow-up, the social worker and the occupational therapist. That is an area of which we, as a college, are acutely aware.
There has been discussion of the 2004 guidelines on that matter. We are conscious of the need to ensure that everything is in place before someone is discharged, and of the need to ensure that we have the resources to support that person, and a contingency plan if something goes wrong. We are increasingly getting better at doing that than we have been in the past.
Some of our mental-health teams have their own recruitment problems, and that creates difficulties. We all know about the number of nurse vacancies. However, good mental-health care requires a proper treatment package for a patient — whether they are at home, in hospital or in the community.
Dr O’Kane’s team provides a treatment plan for when a person is discharged. That may involve the patient seeing a therapist for six weeks, it may require organising medication, or it may involve the person attending some type of day facility. That person should have a treatment plan with which they and their carers are involved.
We are increasingly working more closely with users and carers, and that is a crucial part of our efforts. Currently, we are not bad at that, and we will continue trying to improve what we do in respect of follow-up action.
Someone who has been discharged should always be aware that, in a crisis, he or she can contact the hospital or the CPN. That is happening more than it did in the past; but we could keep on improving the service.
Mr T Gallagher:
There is a short paragraph in your submission about the issue of advertising by alcohol companies and sports sponsorship. You state that that situation is particularly alarming and that we need to examine that. I presume that you are using the royal “we”.
If the members do not mind that term being used, that is fine. I refer to all of us.
Mr T Gallagher:
Do you wish to say anything more about a possible link between that matter and suicide?
We have little doubt that the cult of binge drinking contributes to self-harm and suicide. As a society, we must look at that very seriously. One cannot consider that without addressing some of the prevention issues. There is treatment for addiction, but, in this respect, prevention would be even better.
We must examine the issue of advertising and sponsorship. I am not saying that that should all be banned tomorrow, but there should be a robust debate. We must be direct with the powers that be, and the vested interests. We would be supportive of such an approach, and so would the BMA and the Royal College of Physicians, who have worked with us on addressing liver disease and the risks associated with alcoholism. If the Committee wants our support for being assertive or aggressive in that respect, you are pushing at an open door.
Ms S Ramsey:
Professional sportspersons might not like their big wages being cut.
When we see young people and children with football shirts advertising beer, there is something wrong.
I agree. The two certainly do not marry.
Have all the members had a fair opportunity to question the panel? I am delighted to have had an opportunity to meet you all — particularly Anne, who is a shining example of how one can come through the process successfully.
There are a number of small points that I wish to raise. I am not being flippant, but, given the pressures on psychiatrists, psychologists and the front-line services, who looks after your mental health? I ask because the Committee will be travelling to Scotland to see Roddy McNidder, who oversees the services provided for front-line NHS workers there.
Doctors are at a higher risk of suicide than average members of the population. That is a well-recognised fact.
Ms Ní Chuilín:
That is true of vets, too.
Yes. Psychiatrists and anaesthetists are also prone to that higher risk. In the past, that was ignored. We are dealing with that better than we did in the past. There is some support out there, and that is something that we must examine. As part of the work of the task force, we looked at particular risk groups. We mentioned farmers as a particularly high-risk group, although we did not mention healthcare staff. We are not always great at looking after ourselves. Thank you for making that valid point.
I think that that is an important point, having talked to so many psychiatrists who see the level of despair, anxiety and stress to the point of contemplating suicide. One cannot keep listening without being affected.
So many people visit my constituency office who have borne so many different problems and pressures. The problems that they have to face are remarkable. One family man has had successive tragedies in three successive years. His son was involved in a road accident; and his son is now paraplegic. The following year, his wife had a car accident. She was the main carer for the son, but she cannot now cope because her back is so badly injured. The husband has just had a car accident. The lives of all three members of that family have been wrecked by car accidents. Some of the stories that I have heard are very distressing; and I am not a professional counsellor. Because psychiatrists hear the worst — the darkest aspects of mental health — it is important that they too are looked after.
In my profession, we run sessions called Balint groups, where professionals discuss how they feel about the patients with whom they are dealing and the emotions that are engendered. Dr O’Kane is involved in that. Perhaps we should offer that service to our politicians. That issue is a bit like carer fatigue, and we are aware of that problem.
It is a matter of finding a way to switch off. You folk deal with the worst cases and the lower end of the mental-health spectrum, so I am anxious that you should be looked after. I look forward to travelling to Scotland to hear about the provisions that are in place there for healthcare professionals.
I am delighted that there is now wider public interest in mental-health issues. That has happened for many reasons, not least because the Assembly is now up and running. We are determined to highlight the lack of mental-health facilities and tackle that problem.
Cross-sectoral departmental work is also important. So many young people have told me about how their mental-health and self-harm problems have arisen as a result of bullying. That is a major problem that sets a pattern in young people’s lives and leads to low self-esteem. The Internet also adds to those difficulties. There is evidence of Internet footage that shows people how to commit suicide. Do you write to the relevant authorities and the various Internet agencies to ask them to do as much as possible to remove such material from websites?
I am also aware that, because of text messages, a person can be exposed to bullying in their own home, even their own bedroom. I have heard about all those problems. Have you made any presentations or offered any input on the storylines of television programmes? I know that some of the television soaps have covered that subject.
The Royal College of Psychiatrists centre in London has a very active media unit, and it does a fair amount of work in that area. The Northern Ireland division of the college is trying to be more proactive in those areas. I know that, centrally, the college was involved in discussions on Internet sites, and it worked quite closely with the media on that issue. A part-time media officer has been appointed to the Northern Ireland division, so we are now able to be more proactive in our approach. We have a voice in those matters, just like anyone else. We must contribute on the broader issues that are involved, not just deal with mental illness on its own — and members have mentioned the importance of prevention. We have contributed and will continue to do so, and hopefully we can do more in that area.
How accurate and reliable are the current statistics on deaths by suicide? At one stage, the figure was 150, but it has now risen to 300. How is a figure identified?
The current figure is probably fairly accurate. I carried out some research 20 years ago, and the figures were not that accurate then. Open verdicts were often declared at inquests because it was not considered right to say that a person had committed suicide. However, the figures from the Central Statistical Office are now quite accurate. The figures for the last couple of years have been quite bad, but I hope that, in 10 years’ time, we might look back and say that they were just two very bad years.
In the Republic, it was reported earlier this year that there was a significant reduction in the number of suicides. We should be very wary of year-on-year suicide statistics — it is important to stand back from that because so many factors are involved, and we do not know what they are. I believe that the suicide figures are probably fairly accurate at the moment.
I would have liked to see at first hand the work that is being done in the Mater Hospital. The model that is being used there seems to be the one that everyone is talking about. I know that Sue has already visited the hospital. It would be nice for members to have an opportunity to visit.
Given that the Committee is investigating mental-health issues, we would like to take a more hands-on approach. I appreciate that, in one sense, it might seem invasive, and we do not want to involve ourselves in confidential matters. However, it would be good to see how the services operate. That might give you a headache, but it is important to see how services are delivered. I am very keen to pay the hospital a visit, so I am inviting myself and my Committee members along. A wee bit of power goes a long way. [Laughter.] I hope that the Committee will be able to liaise with you on that.
Thank you for your attendance. This subject is close to all our hearts and, as a Committee, we take it very seriously. All of our constituents are presented with these issues and we must work with one another collaboratively to help to resolve them. Mental-health problems do not respect creed, religion or social status. I hope that we can work together in the future and that we can secure a good outcome for mental-health provision. Thank you for your time.