NORTHERN IRELAND

ASSEMBLY

COMMITTEE FOR

HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

OFFICIAL REPORT

(Hansard)

Suicide – Dr Paul Miller MD DMH MRC Psych

5 July 2007

Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Rev Dr Robert Coulter
Mr Tommy Gallagher
Mrs Carmel Hanna
Mr John McCallister
Ms Carál Ní Chuilín
Ms Sue Ramsey

Witnesses:
Dr Paul Miller, Consultant in General Adult Psychiatry, Mater Hospital

The Chairperson:

On behalf of the Committee, I welcome Dr Paul Miller, who is a consultant in general adult psychiatry. We are looking forward to your presentation. I am glad that you heard the evidence from the bereaved families, and I hope that it has given you food for thought. Perhaps you could even consider, when dealing with mental-health problems, implementing some of the suggestions that were made. Although you have been allocated 10 minutes for your presentation, I will not hold you to that, because I did not hold the families to their time limit.

Dr Paul Miller (Mater Hospital):

Thank you very much. I appreciate the opportunity to make a presentation to the Committee. I am not sure whether the Committee understands how the Royal College of Psychiatrists is set up. As consultants, we sit with peers, and yesterday I informed several colleagues of what I plan to say today; I have therefore incorporated some of their thoughts into the following presentation.

I will outline my qualifications, which will inform the Committee why I am a good person to give evidence. I am dually trained: I hold a certificate of completion in specialist training, as it used to be, with the General Medical Council (GMC), in general adult psychiatry and the psychiatry of old age, which is psychiatry pertaining to those who are over the age of 65. I am currently employed as a consultant in old-age psychiatry by the Belfast Health and Social Care Trust.

However, I am also a trauma specialist, and I work in a trauma practice. I am an eye movement desensitisation and reprocessing (EMDR) consultant. That is a therapy used in the treatment of traumatised individuals, including people who have suffered sexual trauma, trauma as a result of road-traffic accidents, bombings, shootings, or as a result of the conflict. It also includes what we in traumatology call small-t trauma: trauma generated by growing up in home environments that are less than perfect or generated by difficulties such as bullying in the workplace or in schools.

I am an honorary clinical lecturer at Queen’s University Belfast. I am a lecturer in mental health, and I am involved in research and trauma in eye movement desensitisation reprocessing and suicide, along with nursing colleagues, including Iain McGowan. The Committee will have received research on suicide that Iain, Stephen Hamilton and I published. I have also been involved with Professor Ken Kendler on international research into schizophrenia. We have brought some of those skills to bear in research, trauma and suicide.

In addition to working on the medical side, I have been a voluntary Christian youth worker for more than 14 years. I began that work in Londonderry, where I grew up. I then worked for seven years with young people on the Malone Road and, latterly, spent seven years working with young people on the Rathcoole estate on weekly and residential programmes. I was a director of the Northern Ireland Association for Mental Health, and it was a pleasure for me to sit on that panel with the late Professor David Bamford. Latterly, I served as a trustee for the Ardaluin Trust.

I ran a suicide prevention project for two years, which was funded by the Pfizer Foundation. Initially, we worked with young men in west Belfast, but we rolled the project out to the rest of the Province. I have also worked on youth initiatives in west Belfast and trained youth workers on those projects in dealing with people who have mental-health problems — how to diagnose them, how to be aware of them, and how to manage self-harm and suicide. I also helped those workers to deal with other problems that they may encounter. I worked with NHS Ayrshire and Arran on its critical incident stress management team, which was headed by Roddy McNidder and support staff who have lost colleagues or patients to suicide. I am also involved in a mentoring project with consultants in the trust. Having worked in those various areas, I hope that I bring some experience to the project.

That is the remit. However, I hope to allow the Committee the opportunity to question me, because your questions will elicit more information.

The Committee has heard a vast amount about the risk of suicide among young people. One study showed that up to 60% of teenagers experience suicidal thoughts, and one suicide can affect up to 50 people. Moreover, one teenager in 12 suffered from, and reported the symptoms of, depression. I use the word "symptoms", which is different from the "illness" of depression. Some 16% met the diagnostic criteria for the illness. Therefore people often suffer extreme distress. They may not meet diagnostic criteria for the illness of depression, stress, anxiety or post-traumatic conditions, but they may, nonetheless, suffer from extreme psychological distress. It is important that that be managed and dealt with effectively.

In the past 40 years, suicide among teenagers has tripled, but, as an old-age psychiatrist, it was heartening to hear the call for an age-blind service, as research that I carried out with my colleague Iain McGowan showed that, during the Troubles, suicide rates in the over 65s was much lower in the Province compared to those in other areas. We put forward a few hypotheses on why that should be. In a post-conflict situation, it is more likely that suicide rates in the over 65s will increase. We heard today about the suicide of someone who was over 70. People in that age group are also at high risk.

We hear about suicides among young people, but it is important that we think about things in an age-blind way. It is important that young people have access to services because, in many ways, they represent our future but, equally, we devalue those who are over 65. We must consider the value of the person, regardless of age. We must be aware of people who are in contact with services in Northern Ireland in comparison with Great Britain. We tend not to lose people to follow-up services in the same way as they are lost in Great Britain. That is not to say that it does not happen, but we do not seem to have the same problem that services there experience.

The Troubles in Northern Ireland have had an impact. Dr Ciarán Shannon, a consultant clinical psychologist based at Holywell Hospital, has just completed research examining the links between trauma and the onset of psychosis, which is a severe and enduring mental illness. Schizophrenia, for example, is considered to be a psychotic illness. Forty-five per cent of people in the group that he studied had, having experienced severe suicidal thoughts, attempted suicide, and one in 10 was, sadly, successful.

That group’s history of trauma is significant: 50% had experienced childhood sexual abuse, 29% had experienced incest and 48% had suffered physical abuse in childhood. The figure for those who had experienced either sexual or physical abuse was 69%, and 35% had experienced both sexual and physical abuse. Traumas — and not just those related to the Troubles — have affected huge numbers of people, and those traumas have resulted in severe mental illness.

It is important to target those who have been traumatised. I was involved in setting up the primary-care link worker service. The first group of witnesses talked about the importance of accessibility to services. In the Northern Health and Social Services Board area, that service was set up through embedding a trauma panel in the primary-care team at three pilot sites. A therapist qualified in eye movement desensitisation and reprocessing, cognitive behavioural therapy and with basic counselling skills became a part of the primary-care team.

In the pilot study, anyone who presented as having been traumatised by the Troubles was given immediate access to the therapist. We are still putting the final touches to the draft paper of the study. However, almost 1,000 clinical sessions were made available over the two-year period of the study on the three pilot sites. Most patients had to wait less than 13 days before receiving care; of those who had a longer wait, a consultant psychiatrist specialising in trauma advised their general practitioners. Seventy-five per cent of that group said that they found the treatment that they received beneficial.

The general practitioners liked the close work between primary and specialist care, a vital part of which was a sister pilot scheme that involved their training and education, which we delivered to them. At times, it is difficult to persuade general practitioners to engage, not necessarily because they do not want to but because they are stretched to their limit and under significant pressure. Equally, however, as some GPs have a special interest in the subject, they should be the first to receive training.

Dr Bertha Cowan recommended that training, as part of the primary-care link worker service, be rolled out to all GPs. Several months ago, I met the Northern Ireland Medical and Dental Training Agency (NIMDTA); it agreed to that recommendation, and a date has been arranged on which I will take the first trauma training. I see no reason that a similar model cannot be used for suicide. There are already successful channels through which information is passed to general practitioners. However, it is important that GPs first realise why they need to have such information.

The paper that I wrote with Iain McGowan and Stephen Hamilton includes our finding that there is an inverse relationship between homicide and suicide. That is important because it reflects research carried out in areas of conflict across the world. Sri Lanka and Croatia were two exceptions to the rule, although we think that that may be more a problem of how the information was collated. The key finding, however, was that there was a decrease in standard suicide rates for people aged over 65, which begs the question of what is different about that age group.

I wrote down something that Mrs Carson said because I felt that it was one of today’s most important points: suicide is everybody’s business. Everyone must take ownership and work together: the professionals, those working on the ground as part of voluntary and charitable agencies, and you who, as Committee members, can affect statutory bodies and legislation. That is immensely important, as is the role of social cohesion.

My mentor in psychiatry was Dr Peter Curran, who devoted most of his time in practice to those traumatised by the Troubles.

We considered why we were not overwhelmed by the numbers of people who we knew had been psychologically affected by the Troubles. At the time, we believed that that was largely due to increased social cohesion and a sense of purpose in different areas. It is vital that we pass on a sense of purpose to young people at an early stage, as learning it then can see them through into later life.

Unfortunately, we live in an increasingly fragmented society. Consideration needs to be given to emotional literacy training or emotional intelligence training for children and young people. Schools focus almost exclusively on the gathering of facts. I do not wish to be twee, but a quote that I use at the beginning of each of my talks is by Plutarch:

"The mind is not a vessel to be filled but a fire to be lit."

We should teach people to think rather than seek to fill their heads with facts. That is what emotional intelligence involves: helping people to see their inherent value. The value of a person is owned by that person but it is equally owned by the service and by all those who provide a service. If people can own the value of the person, both for themselves and for the people for whom they provide a service, there will be a massive change in the quality of that service.

Suicide is a multi-factorial problem that must be dealt with not just medically, but also at a societal level. Mother Teresa said that the greatest epidemic is that of loneliness. Indeed, Max Lucado said that:

"Loneliness is not the absence of faces. It is the absence of intimacy."

I have worked with young people, mainly young men, for more than 14 years. The young people that I worked with had many friends and many people with whom they interacted. Despite that, and despite seeing a group of leaders, of whom I was one, at least once a week, they did not have anyone who truly knew them and with whom they could talk about the stuff of life. There are many reasons for that: not wanting to burden their families; being pressurised by something; being made to feel shameful about the issues that they were struggling with; or being gagged by paramilitaries, who told them not to talk about an issue.

Many of the issues that I spoke to my peer group about were those that I listed earlier. Consultant psychiatrists across Northern Ireland, who represent a range of specialisms and sub-specialisms, suggested additional issues. I will not identify those specialisms, because that would make the identity of their practitioners obvious.

Clinicians believe that there is an unacceptable input into waiting lists. Instead of clinicians being involved in the timely management of clinical lists and prioritising cases, managers are replacing patients with others who are about to breach time limits for being seen. Those patients may not need assistance as quickly as priority cases, and they are not suffering financially as a result. That is not acceptable.

If people are not seen in a timely fashion that is based on clinical judgement, serious problems will arise. A general practitioner colleague shared one case with me. A gentleman who, sadly, suffered from post-traumatic stress disorder and depression was referred to his GP, who correctly started him on a course of medication and referred him to specialist psychological services. The patient waited three months before being seen by a consultant psychiatrist. After that, he was deemed suitable for referral for psychological talking-therapy intervention. It was 18 months before he was seen by psychological services. During that time, he became an alcoholic and lost his marriage, his children and his job.

That is one reason that, when the primary-care link worker post was established, we sought to do things in a timely fashion. Some people had longer waiting times, but specialists were available in the interim, and that reduced the likelihood of secondary, and unnecessary, psychological problems.

Talking-therapy services must be age-blind; they must be made available to old-age psychiatric services. I have already talked about the likely increase in post-conflict suicide risk among the over 65s.

The Bamford Review is a very timely document but, as clinicians, we feel that it is far too wide and that its recommendations could never hope to be funded.

We wish that the review’s recommendations would be funded, but we do not believe that that will happen. The justified high expectations that people bring to the service add to the demoralisation of a staff who are already pressured. The staff who work in those services do care about what they do. They value the expertise that they have accumulated. Many of them have had to suffer significant difficulties to obtain qualifications and they work with a patient group that is often difficult.

I work in a multi-disciplinary team, which includes clinicians, nursing staff, occupational therapists and psychiatrists. Unfortunately, there are no psychologists. When a patient dies from suicide, clinicians are affected because they have invested in that service. If a blame culture were to persist, something from which we are, thankfully, moving away, the next group of people that ought to be considered when managing death from suicide are clinicians. We have already heard of the high risk to anaesthetists, for example, and it is similar for consultant psychiatrists.

We want to be able to manage the caseload for waiting lists appropriately. Sadly, medication is often used inappropriately — no other service is available, and by prescribing medication, one can, at least, feel that one is doing something. We would like a massive increase in the availability of the talking therapies. The benefits of such therapies are evidence based. Talking therapies are not wacko or out there; they are well researched.

At a recent meeting in Europe with other trauma specialists, the need for such services was discussed, and it is sad that we do not have easy access to them. However, we do have pilot projects, such as the primary-care link-worker project, which has demonstrated that embedding people with the appropriate skills at primary-care level can make significant differences. We saw a massive decrease in the use of benzodiazepines and in the prescription of some antidepressants, and we achieved a 75% satisfaction rate from those who were involved in the service.

Accessibility and staff support inputs are important. The Chairperson has had a chance to meet Rev Roddy McNidder from NHS Ayrshire and Arran who heads up a critical-instance stress-management team. I would encourage the Committee to study what NHS Ayrshire and Arran is doing to manage and support its staff, because a well-supported staff will be able to provide much better services to those who need them. If staff are burnt out, they cannot give anything.

In my peer group, we feel that key importance must be given to social-fabric issues. Attention needs to be given to adolescent addictions. Perhaps a specialised service is required. Alcohol and other substances are a factor in 50% of all suicide attempts, and for 50% of those who die by suicide, alcohol and other substances are found to have been a factor.

Encouraging emotional intelligence and improving the self-esteem and self-value of all people involved in the service is important. That approach must start when people are at school. All services should be age blind. Training for general practitioners and others in primary-care settings is essential, and ways to facilitate the attendance of general practitioners at such training must be considered. The ideal would be to attract people who are interested and motivated. Therefore, making training obligatory may not fulfil that aim. Psychiatry, psychology or specialist counselling must support primary care. To that end, there are good accredited national bodies that could be relied upon to provide people of a good calibre. Taking that approach would assist those in primary-care settings to provide a timely service. In trauma services, the primary-care link-worker project is an example of that assistance.

Resources available for talking therapies and psychotherapy must be expanded. Although, in some cases, medication can help, it can also make matters much worse. Medication is often the fertiliser, but unless someone goes out and plants the seeds and tends the fields, it will not do much good — it is merely wasted fertiliser. Very often, sadly, that is the case.

With regard to the supports and resources available in the fabric of society, including the churches, my identical twin is a Church of Ireland minister in Maghera. He has worked in several parts of Northern Ireland. Rev Robert Coulter spoke of his own training at college, and I assure you that, from my twin’s experience, the training of clergy has not improved. I hope that churches are at least de-stigmatising mental illness. Sadly, however, I still meet patients who have been visited by clergy and told by them that they are bad for having tried to take their own lives. That is unacceptable and it shows a gross misunderstanding of the situation. However, churches have a role to play, not just after a suicide but also beforehand, in stressing the value of the person.

The over-65 age group has a lower risk of suicide, perhaps because personal faith and spirituality are important to them. Those are widely recognised as protection for those at risk of suicide.

I hope that what I have said will provoke discussion. To summarise, I borrow the words of a previous witness — I am sorry that I cannot remember her name — regarding someone who had taken his or her own life, and people in her care who considered taking their own lives. She said that they were desperate, sad and isolated. That is a fact. Those people may not meet the criteria for mental illness, but, in the end, that does not matter. They are significantly distressed and disturbed, and they present to a service that is grossly inadequately provisioned. The services that we can provide are not fit for purpose.

Suitable working, cross primary and specialist care is what is really needed. Medication is a part of that; but talking therapies are also needed. Talking therapy can include presenting to casualty, which, as has been suggested, could be a place of safety where people at risk could talk to someone. The person they talk to does not have to be a consultant psychiatrist.

We must use the resources that we have. I work as part of wonderful, interdisciplinary teams. It is my privilege to do that in both the private sector and in the NHS. We have wonderful systems that allow staff to work together, and we must consider the resource that our staff represents.

The value of the person is the most important thing that I can leave with you. If we respect the value of the person who presents himself with illness and the value of the people who provide services we will all benefit.

The Chairperson:

Thank you, Paul. That was thought provoking. You made the point that management interfered with your waiting list, and that people were moved sideways to accommodate priorities in the structures of care provision. As you have said, that is unacceptable; lay people should not interfere in clinical matters. What can the Committee do to highlight that?

Dr Miller:

We must ask why it happens. People measure what is easy, not what is important — therefore, waiting times are measured. Although it is important that people are seen quickly, that is not the only factor to be considered. Clinicians should be involved in the triage process, where the risks are weighed. Risks will never be zero; resources will always be limited and must be managed as well as possible. One member of my peer group told me that the first name on the waiting list for his clinic had been scored out and a different name inserted. When he investigated, he found that the name had been replaced because time limits were about to be breached. That is unacceptable.

The Chairperson:

The Committee can look into that.

Mr Gallagher:

I, too, wanted to raise and develop that point. It is important that we take the approach that Dr Miller has highlighted. Who will do that? Is it a matter in which the Department or Minister would have to intervene, or would consultants or other professionals have to take a stand on it?

Dr Miller:

A joined-up approach is needed. Clinicians can inform the approach by setting out how the process should work. The first point is that although time limits and such like have been set in an attempt to improve services, time is not the only issue. It is for the Government, probably, to underline that point. Time is important, and I want people to be seen in a timely fashion, but clinical considerations must also be taken into account — 12 years of training is not undertaken just so that somebody else can slot in a patient in place of another purely because of time.

Mr Gallagher:

Like other Members, I have met parents or family members, and it is clear that no service is available. It is such a difficult and harrowing time for them because they are so concerned about the situation. Sharing information with family members, and the relationship between counsellors or psychiatrists and patients, are difficult areas. Sometimes I wish that they would just tell the family a bit more — although I appreciate that there are good reasons for not doing so.

Dr Miller:

I understand that absolutely. In my service, I try to stress the importance of empowering the person as much as possible. Some of the things that are happening at the minute, and the way in which they are happening, disempower people. A person with suicidal thoughts and intrusions feels utterly powerless. When such a person decides in his own mind that it is logical to take his life, then that, in a way, is the only part of his life over which he feels he has control.

Obviously the person’s family will want to know if there is a risk of suicide, and family members will want to hear about the patient’s feelings. However, we must respect the patient’s autonomy, so it is impossible for us to share information unless the patient gives us consent to do so — unless the risk is so great. However, other clinical steps would be taken to help to limit the risk and to protect against it. At all times, it is important to help the patient to feel empowered, so that he can see that there are other doors open to him. He can then, hopefully, work through what are often temporary issues and move forward with the rest of his life.

Mrs Hanna:

Good afternoon, Dr Miller. You are very welcome. I am sure that you must be getting tired; it has been a long session.

You talked about the primary-care link, the importance of teams working together, and the difficulty of implementing the Bamford Review because it is so vast and wide-ranging. Mental health is a complex issue. It is not like a physical problem that can be fixed, and it is very easy to feel daunted by it. However, somebody will have to start putting the building blocks together. I presume that that will have to involve training more personnel and training people to work better together in teams. Some bereaved relatives are still present in the room — and it will be important that all relatives are given support and training and that awareness is raised.

You also talked about emotional intelligence, which is so important. People must be encouraged to talk about their mental health, because that is a no-no for so many of us. We do not want to admit to having problems. There is no doubt that a stigma is still attached to mental health issues and that there is still a fear of them.

Dr Miller:

Absolutely. The issue can seem vast, but, again, that is exactly how our patients feel. The example we use is how to eat an elephant — a bite at a time. Taking small steps is all that we can hope to do. Small steps are significant. For example, a small step could be ensuring a greater availability of counsellors, which would provide opportunities for a person to listen and be listened to, and, in a sense, triaged. It does not help a person to sit in a room without having any input, because he will certainly not be the only person in that room that night. However, it would help to have more counsellors available, who were properly trained to counselling level and accredited by accreditation bodies. Such counsellors do exist, because I work with them in multi-disciplinary teams in the private sector and in the NHS. They can do significant work by listening to people and validating them.

Very often, a young person may feel that they cannot talk to their mum — and perhaps their dad is not around. The mother may also have mental-health issues, and the child may feel that talking to her may make her feel worse. We must create a system whereby we can listen to people. Similarly, the elderly feel that they cannot talk to their children, because they would then become a burden to them. They do not want that to happen, and so they feel that it would be better if they killed themselves. Those people should have someone who is outside the family who can listen and point them in the right direction to seek help.

There are many agencies that do great work. It is important to properly resource people who work at grass-roots level. Not everyone needs to see a counsellor, a psychiatrist or phychologist. It is important to find out what is most appropriate for those people, and the first step is for someone to sit down and listen to their stories.

I know of several people who have had trauma problems, some of whom have been in the system for 16 years, and I have asked them whether they have ever told anyone their story. Their reply has been that their first appointment on the National Health Service lasted for an hour, and the next appointment — if they were lucky — lasted 15 minutes. How does a patient tell someone whom he or she has never met that they have recurrent nightmares of picking up their best friend’s brain in their hand? I do not know of a situation in which that would be possible.

We must try to facilitate people to tell their stories, and that requires a fundamental sea change in the way that things are done. However, there is the danger of some pressures from Government, for example: time, getting bums on seats, and getting numbers through the system.

I am an EMDR consultant. In one of the places where I worked, I represented one of the three consultant psychiatrists trained in that technique in Ireland, and one of a small group in the UK and Ireland. In another area where I worked, I offered to set up a service to provide EMDR. The usual treatment for a single incident trauma, for example, would be six sessions of an hour to an hour and a half, usually on a weekly or fortnightly basis. At that time, the manager told me that the organisation would rather not do that, because it would generate too much work. I asked him whether he would rather that I saw a patient every three months for 15 minutes for the rest of his or her life, and my life. His answer was yes. That is the reality of the situation — we do not have a system that upholds the value of a person. Instead, the system is all about bums on seats, and ticking off numbers. We need a service that is fit for purpose and does what it says on the tin. Unfortunately, the system does not do that at the minute.

Mrs Hanna:

There is an argument about not having quick fixes, but what will work? If there were appropriate training at various levels, it would then be a matter of signposting, whereby people would appear at A&E, or with their GP, and the professionals would know where to refer them, rather than them having to wait for ages to find a suitable person.

Dr Miller:

Really wonderful models already exist in other areas of mental-heath care. For example, there is the Australian model whereby, in first-episode psychosis, schoolchildren are taught about what psychosis is. A child can then recognise whether a friend is acting strangely; say that he or she can hear voices, and know what to do about that. There is no reason why that model cannot be rolled out here, and we should start to talk about such issues. We should help our young people not just to learn facts and pass A levels, but how to think and live purposeful lives.

All the literature on this subject shows that young men aged 18 to 25 are a high-risk group. John Eldredge talks about the issue of the "unfinished man" in our current society. Adolescence, as a societal concept, has been created. Before the creation of the adolescent, young men aged 13 or 14 were engaged in situations in which they were mentored by — or apprenticed to — an older person. They learned from that person the skills of the apprentice and the skills of life. Since the creation of adolescence, young people of that age have been spending time with their peers.

That did not really help anyone to develop fully as an individual. A person might gain qualifications, but their personal development was lost. The idea of rites of passage has been lost in our culture — the idea that there is something that allows a young person to mature and to step up and join the circle. Young men feel a sense of hopelessness and loss of purpose.

When I was growing up, I was a member of the Londonderry branch of the Crusaders, a voluntary Christian youth group, which has recently changed its name to Urban Saints. I had the privilege of chairing Crusaders in Ireland, the Londonderry group, which at the time was an all-boys group and was run by an older gentleman called T S Mooney. He had a saying for the boys, which was that they should have a Bible in their hand, a Saviour in their heart and a purpose in their life.

Whether one accepts the Christian faith or not, a purpose and sense of spirituality are important. Whole generations of young people are growing up without any sense of purpose. When I worked in Rathcoole, I encountered people from second- or third-generation families who had never worked and did not know what work was like. Their sense of purpose was gained from joining paramilitary organisations that gave them guns and allowed them to extort money from other people, which made them feel important.

Unless society changes so that people know their value, whatever their age, suicide will always be with us, because suicide is about loneliness, emptiness and a lack of intimacy that allows people to connect truly with others. That requires us to teach people and to talk to them about their emotional intelligence, and to allow them to learn that it is OK to talk about emotions and mental illness — that those are not strange things that should be set aside. That is a job for everyone in society, whether they belong to Churches, GAA clubs or whatever.

The Chairperson:

You are getting off quite lightly, Paul, because you have given us so much detail and have been so interesting to listen to. Thank you for your presentation; there is much there to give us food for thought.

Dr Miller:

The primary care link worker document should be ready soon. It will be a valuable reference tool for the Committee.

The Chairperson:

That will be very helpful.

Mrs Hanna:

Are there any more details available about the proposed visit to Ayrshire and Arran?

The Chairperson:

I am aware of that proposal, and I am ready to make arrangements with the Committee to either go over to Ayrshire and Arran or to have its representative come here. That is important, because we are dealing with several mental-health issues, and we want to keep them at the top of our agenda as much as possible. Thank you very much, Dr Miller.