Psychiatric Services: Motion March 31st, 1999 Dr. Henry: I move: That Seanad Éireann calls on the Minister for Health and Children to take immediate action to tackle the lack of acute psychiatric beds and other problems in the psychiatric services.

I welcome the Minister to the House and am aware of his interest in this area. However, I was disappointed that an amendment was tabled to the motion, as there is no service so good that it cannot be improved and that would not benefit from being improved speedily rather than slowly. I brought this motion before the House because I attended an interesting conference last week which was attended by some of the Minister's officials. About 30 years ago there was an international consensus among those treating patients with psychiatric disease and among communities in which such patients lived that it would be better if people with psychiatric disease were treated in the community where that was possible rather than in large mental institutions as was the international practice. Society in general agreed and in many countries, including Ireland, the large psychiatric institutions were closed. However, there are some psychiatric patients who require in-patient treatment, and with the decrease in the number of beds available a situation has arisen where patients with an acute exacerbation of their illness cannot be admitted. Regrettably, this can happen even when patients may be a risk to themselves or to other people. In addition, patients with long standing illness who may need in-patient treatment cannot be re-admitted. This is very important from the point of view of the patient's family, who may have been extremely supportive of the patient. Families feel neglected when they cannot get respite in the event of an acute exacerbation of a person's illness. When we talk about waiting lists we are inclined to talk about hospital waiting lists for physical problems. However, it must be made known that there are also waiting lists for psychiatric beds. The report commissioned by the Department of Health and Children and carried out by the Health Research Bureau is excellent. It was carried out by Fiona Keogh, Ann Roche and Dermot Walsh and is entitled "We have no beds: an inquiry into the availability and use of acute psychiatric beds in the Eastern Health Board region". The Health Research Bureau held an excellent meeting to discuss it last week. The situation with regard to beds is interesting as it appears we have an adequate number of acute psychiatric beds when compared to international norms. The study focused on the use of acute beds and whether they were being used properly. The study was carried out in the Eastern Health Board area, but an examination of the last report of the Inspector of Mental Hospitals suggests that the experience in the Eastern Health Board area, where the worst delays occur, does not differ greatly from other regions in many respects. I am disappointed that we still have not discussed the 1997 report of the Inspector of Mental Hospitals, although it was published much earlier than usual as the Minister promised. The report is interesting as there has been a dramatic improvement in the situation in psychiatric hospitals. Last year the House discussed the report of the Inspector of Mental Hospitals for the first time in the history of the Oireachtas. When such reports are made public there is a greater impetus for action on a local level. Mental illness is higher in areas of highest deprivation. The report says that urban areas can be associated with a high rate of social and economic problems which have been shown to be related to increased psychiatric admission rates. It also says there is a tendency for people with psychiatric disorders to be concentrated in inner cities. This is an international and not just an Irish problem. If one visits London, one sees the same situation as exists in Dublin. The same can be seen in Rome, except that it is much worse there because their shortage of beds is even more acute. The motion I tabled is not an attack on the Minister, his Department or the Government but to try to get some sense of urgency about what needs to be done because we have a serious problem. Furthermore, when we talk of waiting lists, we are usually referring to general hospitals waiting lists. The study surveyed district electoral divisions to see which had the greatest deprivation. It found the areas with the greatest number of deprived district electoral divisions also had the least in the way of services. This is the same in all cases; those who are best able to organise themselves are the most likely to receive the best services in their areas. This is not surprising but it shone out in the report. The greatest proportion of deprived areas are in the catchment areas in the west of the city and in the north inner city. These were also the areas with the fewest services. Eight of the ten most deprived areas in the country were in these two locations. Another important factor in psychiatric services is the age of the population. The population of Ireland is ageing and people in older age groups are more likely to develop dementias which can be an important cause of acute admissions. At the same time, an increasing number of people are going from adolescence to adulthood. This is a time when major psychiatric illnesses, such as schizophrenia, often become florid. Most catchment areas were seriously short of old age and adolescent psychiatric facilities and there was none in some areas. Another problem which was relevant to the survey was the influence of homelessness on the number of acute beds in the psychiatric services. This is an increasing problem in Dublin. We know there is an association with psychiatric illness but the number of beds for homeless people in hospitals, be they psychiatrically ill or otherwise, is deplorably low in the city. I have heard people say no one need be homeless in the city. I do not believe that. Some people are difficult to house because they prefer a life on the streets. I walk down Baggot Street every night and, between the back of Leinster House and Waterloo Road, I can meet ten people half of whom suffer from psychiatric illnesses. Why are we so short of beds? The investigation felt that about 80 to 85 per cent of cases in the cohort studied had been justified in their admission to hospital. However, it pointed out that 40 per cent of those admissions took place between 6 p.m. and midnight, a time when only junior hospital doctors were in charge. The Minister suggested to the manpower forum the other day that it should address the hours worked by consultants. This could be important in the psychiatric service regarding the admission of patients to hospital. Many patients who want to be admitted are drug addicts or alcoholics who are sometimes apparently escorted there by members of Alcoholics Anonymous. In many cases they seek a night's lodgings. However, it is difficult for a junior doctor to refuse admission, especially if a threat of suicide enters the equation. It would be better if the Minister's suggestion that the hours worked by consultants were examined and if there were a higher proportion of consultants working at times of high admission because they are in a better position to refuse admission than people with less experience. There is also the constant threat of litigation. It is extremely hard on compliant patients to have drug and alcohol addicts who use the hospital as lodgings admitted late at night, and it is undesirable. They can be moved from bed to bed, from ward to ward and even from hospital to hospital. I am a conservative person and expect to wake up in the morning in the bed in which I went to sleep the night before. One can imagine what this moving must do to a person with a psychiatric illness. One can also imagine the outcry there would be in the newspapers if people went to bed in Beaumont Hospital and woke up in the Mater Hospital. It is unfair that psychiatric patients should be treated in a manner in which neither physically ill patients nor members of the population would be treated. About 50 per cent of patients are discharged after a short stay in hospital, but there are some groups it can be difficult to discharge. Women, married men and those who were employed can be discharged back into the care of their families or friends much earlier than young, homeless, unmarried and unemployed men. There is nowhere to send the latter. Communities welcome the increased use of small hostels, sheltered accommodation and day hospitals for psychiatric patients as long as they are not in their locality. Even if funding is provided for them, there may be trouble establishing community psychiatric services. Along with this is the serious situation regarding prisoners. The report by the Director of Prison Medical Services said some gloomy things about patients with psychiatric illness. There is a waiting list for admission to the Central Mental Hospital, Dundrum, and it is freely admitted that the treatment of prisoners with psychiatric illness is unsatisfactory. Apparently about one-third of prisoners have a psychiatric illness. While at present these patients are under the remit of the Department of Justice, Equality and Law Reform rather than the Department of Health and Children, many people, including the Director of Prison Medical Services, think it should not be so and that they should be under the care of the latter Department. There is nothing for these patients on their release. In the recent case of Fr. Fortune, a judge tried to admit him to the Central Mental Hospital, Dundrum, but could not because of a dispute. The priest was sent to Mountjoy Prison, was discharged on bail and committed suicide. No matter how vile his alleged deeds, this was unacceptable and it begs the question, to how many others did this happen. We know of the rising suicide rate and the fact that many victims suffered from psychiatric illness. Would any of them have been greatly assisted if there had been an acute bed available?

Families who are normally supportive become frustrated if they cannot get a service for their ill family member when they need it. It is especially ridiculous that alcoholics can easily gain admission to these units. Doctors are in a vulnerable position if they refuse to admit them. Dr. Moosajee Bhamjee went before the Medical Council last year because he refused the admission of two alcoholic patients at night. The wives of these men reported him to the Medical Council. While he was exonerated, he wrote movingly of the great distress he suffered while being investigated. Hospitals need to have a policy when a patient is admitted of putting in train a process of management towards their discharge. The severity of the illness should be assessed rapidly, as it usually is, but frequently little thought is given to the onward progress of the patient until it is time to discharge them. This is a multi-faceted problem and multi-faceted solutions are required promptly. The report reckoned that 91,000 bed spaces were wasted. At £100 a night, that is £9.1 million. The Minister could do a great deal with that money, so there is a need to rapidly tackle the abuse of acute beds in the psychiatric service. Mr. O'Toole: I second the motion. The Minister should consider accepting the motion as it has been tabled. The amendment is unnecessary. The motion is not intended and should not be interpreted as a criticism of the Minister or the Department. It points to a flaw in the system. I was shocked when I read the report to which Senator Henry referred. I am interested to hear the Minister's response. Neither he nor his Department may accept some of the conclusions drawn in the report but I have read the report from the point of view of one who has no expertise in the area of psychiatric illness. It points to a series of flaws and problems as much to do with the management as the lack of resources in this specific area. It appears to be a classic example of somebody kicking a problem down the line until it finally reaches a place where the buck stops. Too many bucks appear to stop in this area, some of which are not the responsibility of the Department, which in many ways is left to deal with the difficulties and issues that should be addressed elsewhere. We must accept the findings of the survey which indicates that when it was undertaken, there were 91,500 inappropriately used bed nights or bed days in the Eastern Health Board area. I hope the Minister will respond by saying he does not accept these were inappropriate but, if they were, the problem needs to be addressed because it creates knock on problems to the point where rehabilitation places appear to be almost non-existent. There also appears to be a serious shortage of community based places. Some of the problems here are the result of changes in society. Before the age of the nuclear family, extended families became extended neighbourhoods. In such circumstances those who were not as mentally strong as others were cared for by the community in the sense that people looked out for each other. People who would have been kindly described as "not the full shilling" 50 years ago might have continued to live in their community but modern society has lost that caring idea of an extended family. People tend to move away from their birthplace which contributes to the problem. An extraordinary number of admissions were made by inexperienced medical staff, presumably junior consultants working at night. That is a worrying systems flaw. Before somebody is admitted certain processes should be adhered to, although this may mean that people who find themselves in trouble or are suicidal may be turned away. I do not pretend to know the answers to these problems. It is worrying if only one - third of acute admissions were made by consultants. It must also be a cause of concern to the Minister in terms of the most appropriate way of spending taxpayers' money. I would be interested in the views of those working in the service and I look forward to Senator Glynn's opinions. The question of homelessness must arise. When the Minister is fighting for resources for Health at Cabinet, is this an appropriate area of expenditure for the Department? It might be dealt with more effectively in another area rather than having it dumped in this Department, which is what appears to be happening. The report deals with the intensive care units in the regional health board area where there are 57 beds which appear to have been taken up by long stay patients or those on routine admissions. That must be a source of worry to the Minister. Who decides to call a halt to this process? The report is good at stating the problem but its recommendations are inadequate. It contains a huge amount of information which is backed up by statistics but its recommendations are more philosophical than specific. A huge number of these problems are rooted in alcoholism. We should look carefully at alcohol programmes in the workplace. When people can no longer cope with alcoholism the first thing they lose is their job, followed by their family and so on. The problem becomes more acute in the workplace. It would be helpful if there were ways for management to identify the attendant problems associated with alcoholism and give people Hobson's choice - to take treatment or lose their job. There is a problem relating to a lack of self-esteem which is almost endemic in aspects of Irish society. Too many parents put down their children rather than encourage them. There is a flaw in the education system here also. We should build children's self esteem to a much greater extent so that they have a greater sense of themselves when the reach the problem years, in their teens and later. We should take the homeless out of hospitals. They are a problem for local authorities, not for hospitals or the psychiatric services. There should be free admission assessments and there should be a community based level of care between the acute level and intensive hospital care. The aspect of rehabilitation should require a more focused investment. There are ways in which this can be done. I ask that amendment No. 1 not be moved. It is not required. What we need is a debate on the issue. Dr. Fitzpatrick: I move amendment No. 1: To delete all words after "That" and substitute the following: "Seanad Éireann acknowledges the initiatives taken by the Minister for Health and Children to provide for patient access to acute psychiatric beds and the development of a modern psychiatric service". Minister for Health and Children (Mr. Cowen): The moving of an amendment does not disbar the House from debating the merits or otherwise of any motion or amendment. To allow the motion to stand would suggest that nothing is being done to try to improve the situation. The Government must take every opportunity to put in context the problems that exist, whether they relate to this service or any other and let the House decide on its approach. Last week the Health Research Board launched its report documenting the findings of an inquiry into the availability and use of acute psychiatric beds in the Eastern Health Board area.

The publication of the report is timely following claims in recent years of difficulties encountered by patients in gaining access to acute psychiatric beds in the Dublin area. It has been the case in the Eastern Health Board area that beds have been unavailable in some instances for patients with acute illnesses requiring hospitalisation. This has led to a system of transferring the patients for short-term purposes from one catchment area of service to another with consequent delays and disruption of patient to patient care. Views have been expressed that there are insufficient acute beds to meet the needs of the population being served by the mental health services of the Eastern Health Board. It was in response to this problem that my Department requested the Health Research Board to examine the availability and use of acute psychiatric beds in the Eastern Health Board area. Before commenting on the findings of this important report, I will outline basic facts relating to the provision of acute psychiatric beds in the Eastern Health Board area. The Eastern Health Board has the lowest provision of psychiatric beds despite having the most urbanised population and a high proportion of deprived areas compared with other health boards. While it is acknowledged that both these factors place greater demands on psychiatric services, it should be borne in mind that the current provision of beds, at 0.43 per thousand of total population, is not far off the planning norm of 0.5 per thousand as recommended in the report of the study group on the development of psychiatric services, Planning for the Future, which was published in 1984. Today this report remains central to Government policy on the development of psychiatric services. Planning for the Future recognised that as a more comprehensive, community-based psychiatric service starts to replace institution-based services, the 0.5 per thousand in-patient planning norm would need to be revised downwards. Therefore, when one takes account of the considerable expansion of community-based care facilities in the Eastern Health Board area since 1984, the 0.43 per thousand population ratio of beds would appear to be appropriate to meet the acute psychiatric in-patient care needs of the board's catchment area population. One must also take account of the bed requirements for long stay patients, the disturbed mentally ill and the increasing demands placed on general mental health services by psychiatry, of old age, to name but a few service components making up the overall provision of mental health services. It seems the question which should be asked is not whether enough beds are being provided but if the current bed provision can be used more effectively and do we need alternatives to acute beds. Acute bed provision is only one component of a complex, interdependent and interrelated mental health service system. Having briefly read through the findings of the Health Research Board report, the results indicate that while there appears to be an adequate number of acute psychiatric beds in the Eastern Health Board area, an inadequate number of these beds are available for acute needs by virtue of occupancy of a large number of beds by non-acute patients. A striking finding was that close to half of the patients surveyed were judged not to require the acute beds they were occupying. While the admission of these patients may have been appropriate on the date of admission, their occupancy of the acute beds at the time of the Health Research Board research was judged to be inappropriate. I acknowledge the existence from time to time of the problem of bed blocking by non-acute patients which results in patients being transferred, sometimes at short notice, from one service to another to make beds available to patients for whom admission is deemed imperative. However, initiatives are being taken by my Department to impact positively on the situation. Progress has been made towards providing good quality, general hospital based care for acute psychiatric illness in the Eastern Health Board area. A number of acute psychiatric units in general hospitals including Beaumont Hospital, St. Vincent's Hospital, Elm Park, and James Connolly Memorial Hospital are at advanced stages of planning and will come on stream in the not too distant future. The new acute psychiatric unit at Tallaght Hospital is ready for patient care. I am conscious of the delay in opening this fine facility which will replace old care facilities at St. Loman's Hospital, Palmerstown. The industrial relations issues which have frustrated the transfer of patients to a more acceptable care environment in Tallaght Hospital cannot remain unresolved indefinitely to the detriment of patients. I remain hopeful, however, that commonsense will prevail and that the new unit can open without further unnecessary delay. The provision of these new up-to-date equipped acute psychiatric units should help to alleviate problems with acute psychiatric care in these catchment areas and reduce the need to transfer emergency and short notice admissions to other catchment areas. The key to proper and efficient use of acute beds lies in the utilisation of consistent and correct admission policies to acute in-patient facilities. I note from the Health Research Board report that admission and discharge policies in operation are of varying quality and that the decision to admit to acute beds was often taken by inexperienced medical staff with less than one third made by consultant psychiatrists. I welcome the fact that Senators proposing the motion agree with the proposal being brought by the Department in the discussion on medical manpower policies. It appears to me that health seems to be the only area in which we seek to invest continually in improving capital facilities and the working environment in which people operate, but there seems to be a reticence among some professions to recognise that it means they must come up with far more flexible working conditions and practices. That is an issue with which the professions must grapple because the taxpayer is prepared to provide substantial capital investment programmes, not only in mental health facilities but in health facilities generally. I thank my colleague, the Minister for Finance, who greatly increased the capital programme, but there seems to be this idea that that is an entitlement in itself and that it is unreasonable for the Department, the Government or the political system to insist on far more flexible working conditions to be applicable in circumstances where we, on behalf of the taxpayer, are prepared to modernise and, indeed, in many instances transform the system from old 19th century type institutions. That is simply a quid pro quo which should be accepted by everybody in the system. One would expect from professions that that would be an understanding which does not require too much debate but, as we know from the medical manpower policy discussions, there is an amazing reticence to acknowledge that that is a quid pro quo which is vital as far as the Government and the people, who are prepared to put up their own money to try to improve the services, are concerned. In industries getting further capital investment, the trades union movement has shown itself admirably able to come up with the sort of flexible working arrangements which would keep industry competitive. It is not too much to ask that the professions would recognise similarly in relation to developing services, particularly health services which are so important to the people, that the same principle should apply. The report states that only 53 per cent of patients surveyed received a full psychiatric assessment prior to referral for admission. It would appear, therefore, that appropriate admission policies need to be implemented and the implementation of such policies should be monitored, possibly through the use of audits. I agree with the thrust of the report that special attention should also be paid to pre-admission assessments and that the assessments should, as far as possible, be carried out for all patients by senior medical personnel in community-based settings. The primary focus should be on assessing patients with a view to directing them to the service most appropriate to their needs, which may not always be in-patient admission. My Department's policy document Shaping a Healthier Future recognises the importance of the pursuit of quality at all levels of service provision and lays emphasis on constantly measuring and evaluating quality of care. The Inspectorate of Mental Hospitals plays a crucial role in the delivery of quality mental health services through monitoring and reporting on the quality of care in mental health institutions and services. The inspectorate's annual report provides an objective account of standards of care and accommodation in the mental health services and has been a major catalyst in improving standards of patient care with simultaneous advances in the quality of life of patients. In pursuance of excellence in care delivery and to assist health boards and individual service providers in attaining this objective, the inspectorate recently deemed it prudent to formulate guidelines on good clinical practice and quality assurance in mental health services. The Guidelines on Good Practice document, published by my Department in 1998, has been widely circulated to all providers of mental health services in the country. They are designed to stimulate discussion and examination by service providers of their services and practices with a view to improving services, and refer to important service delivery issues such as bed management policies. The guidelines, in common with a central finding of the inquiry report, stress that there should be an agreed and fully documented admission policy and procedure in each service. The guidelines also underline the need for a clinical review on a daily basis for patients admitted involuntarily. The inquiry report stresses that good community care, with an adequate number of graded, supervised community residences and comprehensive rehabilitation services, are required to counter the pressure on acute beds in psychiatric hospitals and units and to provide alternative placement for those inappropriately occupying acute beds. It refers to a need for a greater variety of supported accommodation, especially of "step-down units" or "super high-support" residences. Two-thirds of patients inappropriately occupying acute beds could be placed elsewhere, without too much difficulty, were community-based residential facilities available. As we move towards the new millennium, mental health services are being developed to a modern mental health care standard. Great strides have been taken under successive Governments since the publication of the policy document Planning for the Future in 1984 in developing a service which is comprehensive, community based and integrated with other health services. The Eastern Health Board has been prominent in the delivery of services from a narrow hospital based service to a more comprehensive, accessible and patient oriented service. This shift in the delivery of services from predominantly hospital based care has been extremely successful and has been brought about through broad acceptance and support of the recommendations of Planning for the Future. Successive Governments have adopted this policy and the shift in mental health care from an institutional setting to a community based setting has resulted in many benefits aside from more appropriate use of inpatient facilities. Mentally ill patients now have increased self-esteem and can look forward to living normal and fulfilling lives in their own communities. I am pleased to inform the Seanad that while the demand for capital resources to facilitate development of community based care facilities for the mentally ill is constant, increasing levels of funding are being made available to meet this demand. There has been an injection of approximately £19 million in capital funds since 1994 in the mental health services with £12.9 million of this total being provided in 1997 and 1998. This has assisted the gradual shift from a predominantly institution based mental health service to a more community directed service. Nonetheless, it is recognised that much remains to be done to improve accommodation in some psychiatric hospitals and to establish a properly structured community psychiatric service in all health board areas. I referred earlier to initiatives being taken in the Eastern Health Board area to provide for new acute psychiatric units attached to general hospitals. On a national scale, similar action is taking place to provide new acute psychiatric unit facilities. Acute psychiatric units are being planned and will become operational in the medium term in the following general hospital locations: Portlaoise, Nenagh, Kilkenny, Ballinasloe, Mercy Hospital, Cork, Ennis, Sligo and Castlebar. To avoid the difficulties encountered in the Eastern Health Board relating to the availability of acute psychiatric beds, I am conscious of the need to continue the development of a range of community based care facilities for the mentally ill to complement inpatient facilities. The factors which have contributed to pressure being placed upon the availability of acute in-patient beds in the Eastern Health Board area are replicated throughout the country. For example, there is a need to operate appropriate admission and discharge policies for acute inpatients in order to guard against instances of inappropriate bed occupancy thus leading to a potential shortage of acute in-patient beds. I am aware that the most effective means of ensuring that proper admission and discharge policies succeed is to provide the necessary alternative and appropriate care and treatment facilities to persons with a mental illness who might otherwise occupy in-patient beds due to the lack of such facilities. I am committed to the core objective of Government policy to provide for a comprehensive mental health service to meet the needs of persons with varying levels of mental illness. I would like to mention two areas of mental health service development being actively pursued by my Department which I consider to be important in the overall scheme of health service developments. Steady progress has been made in the development of consultant-led child and adolescent psychiatric services throughout the country. The recruitment of consultant child psychiatrists and other health professionals specialising in the care of children and adolescents with mental health problems has been accelerated and all health boards now have dedicated child and adolescent psychiatric services headed by a consultant psychiatrist. An adviser in child and adolescent psychiatry was appointed to my Department in 1995 to assist with the implementation of the recommendations of the report Planning for the Future in relation to child and adolescent psychiatry and to assist with the formulation of policy on the future development of these services.

A review of the nature and extent of existing services has been carried out and as a consequence, a draft policy document for the further development of child and adolescent psychiatric services which includes an identification of areas of particular need has recently been completed and circulated to the health boards for consultation. At the other end of the age spectrum, the demographic situation in relation to older people clearly indicates that the number of persons in this category will increase significantly over the next 20 years. This increase will require the development of specialist mental health services which will meet the specific needs of older people. Psychiatry of old age is therefore a key area for development in line with the recommendations of the report, The Years Ahead - Policy for the Elderly, which recommended the establishment of specialised services for the elderly mentally infirm. The integration of community and hospital based psychiatric services with geriatric medicine to provide comprehensive and appropriate packages for older people is progressing. Old age psychiatry services are currently being expanded and the Eastern Health Board has four old age consultant teams in place. Additional resources have been, and will continue to be, provided to enable further improvements to be undertaken on a phased basis, over the coming years. A further important initiative being taken by me is the replacement of current mental health legislation which dates back to 1945. A new Mental Health Bill is currently being prepared in the Office of the Attorney General and it is envisaged that the Bill will be published in the next Dáil session. The new Bill will bring Irish legislation into conformity with the European Convention on Human Rights and will provide a modern framework for the care and treatment of persons with a mental disorder who refuse or who are incapable of seeking treatment in their own interest or in the interests of others. In supporting the motion, the provision of acute psychiatric in-patient beds for the care and treatment of persons with a mental illness cannot be considered in isolation from the development of other components of a comprehensive mental health service. The key to effective and efficient use of acute psychiatric beds lies with clear and unambiguous admission and discharge policies for the beds in tandem with the availability of a range of community care facilities for persons with varying levels of mental illness. The main recommendations of the health research board inquiry report merit serious consideration and will have equal relevance outside the Eastern Health Board area. I remain fully committed to the continuation of the pace of development of services closer to the homes of people who can benefit from such care facilities with the least disruption to their daily lives and with special attention devoted to the development of child and adolescent and old age psychiatry. I am determined that all sections of our society receive modern standards of mental health care, irrespective of age, location of home or category of mental illness. I commend the motion to the House. Mrs. Jackman: I am glad to support the motion tabled by Senator Henry. When she raised the publication of the inspectorate report last year, the Minister responded quickly; I look forward to reading this year's report. It is obvious that the Eastern Health Board area report is relevant. However, I ask the Minister to ensure the same health research unit should investigate the Mid-Western Health Board. The Minister said the main recommendations of the health research board inquiry report merit serious consideration and will have equal relevance outside of the Eastern Health Board area. I hope it looks at the Mid-Western Health Board. The Minister also referred to the McCarthy report on the appropriate development of child and adolescent psychiatric services nationally. I hope the Minister has received the recent survey on attention deficit disorder which I carried out with a research unit. It highlights the lack of provision of ADD services and was adopted unanimously by the committee on health and children. The McCarthy report recommends the provision of the best possible psychiatric treatment for children nationwide. The Minister referred to the fact that because we have an ageing population, we must look after the needs of the elderly. However, we must also prioritise the need for consultation with and support for agencies working with children and adolescents. The problems experienced in the adequate provision of psychiatric services to both children and adults are nationwide. They are particularly acute in Limerick and I am sure I will be forgiven for highlighting the area I know best, which is the mid-west region and Limerick City and County. Senator Henry referred to the problems in urban Dublin. I am sure if the same inquiry was carried out in Limerick, the findings would be similar. I wish to highlight six problems: the shortage of acute psychiatric admission beds, particularly the lack of a unit in the regional hospital specifically designed for acute admission of children and adolescents under 16 years; the lack of a secure unit; the delay in the provision of independent living units for psychiatrically disturbed and mentally handicapped patients in Lisnagry, which was suppose to happen but has not; the lack Of nursing home-type accommodation staffed by psychiatric nurses for long stay geriatric psychiatric patients currently at St. Joseph's Hospital and hostel accommodation for long stay patients who do not need hospital based services but require high support accommodation; and the provision of an observation suite in 5B, the acute admissions ward at Limerick Regional Hospital for disturbed patients. The position on the shortage of acute psychiatric admission beds is that ward 5B at Limerick Regional Hospital operates at full capacity at all times. It cannot cope with the demand. There is also a waiting list for admission, which is intolerable, and the overflow is accommodated by moving patients to ward 10 in St. Joseph's Hospital or by direct admission to that ward. That is not acceptable. The facility for acute psychiatric patients are inappropriate. Ward 10 is the only secure ward in the region and is used to accommodate seriously disturbed patients. Such patients are held there for their own safety and that of those around them. Acute psychiatric patients have different needs. They may need only a short stay in hospital, following which they can be returned to the community and supported by out-patient services. If further hospital intervention is necessary more than likely it would not be within the confines of a secure ward. I wish to refer to the lack of an acute unit specifically for children and young adolescents under the age of 16. At present they are admitted to ward 5B which is inappropriate. As we know, children and young adolescents suffer from psychiatric disorders unique to their age group. People under 16 years of age are not adults and they cannot hope to recover or receive the support they need if they are surrounded by adult acute patients, seriously disturbed patients or geriatric acute psychiatric patients. These young patients are isolated and their peers are frightened to visit them. They would visit them if they were in a separate area. They are shoved into the ward because there is no other place for them. They should not be exposed to the categories of patient I have outlined. Senator Henry referred to waiting lists for physically ill people. Nobody talks about waiting lists for the very young. It is a taboo subject. Senator O'Toole referred to the feelings of young children. As a teacher, I know they suffer from a lack of self-esteem and peer pressure. One can imagine how they must feel when they have a psychiatric problem and are shoved into a ward with older people who suffer from a variety of illnesses. That is what is happening in the Limerick area. Young also have different environmental and occupational therapy needs. They need a homely environment, their own delights of music, television and an environment for their friends to visit. The staff must have appropriate training to deal with paediatric-psychiatric admissions. A secure unit is essential in the Limerick area. By their very nature, these patients are held against their will for their safety and that of the community. One to one care is a waste of a nurse. If they were in a special area, one nurse to four patients would suffice. The expertise of nurses is being wasted when a special unit does not exist for the needs of psychiatrically disturbed patients. The provision of three bungalows - independent living units - for mentally handicapped patients was promised a long time ago. The approval of tenders has been delayed. The tenders are out but there has been no communication from the Department on that issue for 12 months. This is an important matter and it will not go away. There is no nursing home accommodation for long stay geriatric psychiatric patients in St. Joseph's Hospital or hostel accommodation for long stay patients and there is no observation suite in Limerick Regional Hospital for disturbed patients. There is serious pressure on the acute psychiatric services in Limerick city, county and mid-west region. Nursing and medical staff continue to do their best and, although these problems are experienced nationwide, Limerick city would be a case in point to show the acuteness of the problem. We have an above average suicide rate among the young adult male population. As we are nearing examination time, sadly a few more statistics will probably be added to the suicide file. I appeal to the Minister to consider the needs of the young people and adolescents. This need has been mentioned by Senator Henry and others. Dr. Fitzpatrick: A recent study commissioned in the Eastern Health Board area shows the problem was not due to the lack of acute psychiatric beds but to non-acute patients occupying acute beds. This dilemma occurs throughout the hospital system. Children who are not sick occupy beds in Temple Street Hospital because there is no other place for them to go. Elderly patients occupy acute beds in the Mater Hospital while they await beds in non-acute but high support medical facilities or nursing facilities. It is interesting that 45 per cent of acute beds are occupied by people who do not require acute psychiatric accommodation but are awaiting alternative accommodation. The Government cannot be faulted for the funding it has provided for psychiatric hospitals. Capital spending has increased from £1.1 million in 1996 to £6 million in 1997 and to £6.9 million in 1998. However, there are problems. With the increase in the number of people who live to old age, there has been a consequent knock-on effect on psychiatric services. The Eastern Health Board has taken steps to deal with this by establishing departments of old age psychiatry. These departments provide an outstanding service in the community. The aim of these services is to keep elderly people who suffer from mild to moderate, and sometimes severe psychiatric, conditions within their home environment. If one takes elderly patients out of their environment one can precipitate a psychiatric crisis. They are well able to lead adequate, rewarding and content lives in their homes with adequate medication, and support from their families and the social and medical services. When I was a young medical student in the 1950s and 1960s the buzz words were "community psychiatry". I warn politicians, senior administrators and Ministers to beware of buzz words in medicine because fashions come and go. Community psychiatry was very fashionable then. It was foisted on us without thinking through the consequences of what we were doing or were about to do. In an extreme case, a senior psychiatrist in Italy closed down his psychiatric hospital and put the patients out on the street for the community look after them. Before patients can be moved from a hospital setting, particularly a psychiatric hospital, a facility must be in place to receive them. That is being done now. A very senior psychiatrist in this country appeared on the television with his sleeves rolled up and a lump hammer in his hand ready to knock down the walls of a psychiatric hospital. What was not shown some years later was the reinstatement of those walls, not to stop the patients getting out, but to stop the lowlifes getting in and disturbing, annoying and plundering the belongings of patients and staff. The idea of community psychiatry was avidly bought by patients, their families and the Administration of the day. Patients and their families bought the idea because it offered a more humane way of treating people with psychiatric problems and it removed the mental hospital stigma and Administration bought it because if offered, as they thought, efficiency in the treatment of patients with psychiatric problems and it improved the service. Everyone was wrong; patients relapse. New patients are coming into the system every day and new and more expensive drugs are now available. As always there are patients who require high support care in long-term surroundings by highly trained and skilled staff. The provision of these services in humane and appropriate surroundings does not come cheap. We tend to forget that psychiatric hospitals were originally called asylums - places where people could retire from the stresses and troubles of the world. In the rush to modernise the language used in medicine we forgot that some of the words we used had real meaning. Many of those meaningful words were replaced by jargon which dehumanised our understanding of psychiatry, what it is about and patients' needs. I remember attending a meeting where people talked about "decanting" patients. I had to pinch myself; I wondered if they were talking about wine or people with serious problems. There are problems with the provision of psychiatric care. Too many patients are taking up beds not appropriate to their needs or condition. There is a shortage of rehabilitation places for patients. There is a very low level of community-based emergency outreach crisis and prevention services and, in my constituency, there is a significant amount of social deprivation. We should never underestimate the part which social deprivation can play in psychiatric illness. The old psychiatric hospitals have outlived their usefulness but we cannot ignore the fact that there is a need for hospital beds for certain types of psychiatric patients. There is also a need for long-stay psychiatric beds requiring various degrees of medical and nursing support. Historically, psychiatric services have been provided by the State rather than voluntary bodies. As a result an element of demarcation has grown up in the psychiatric area. A psychiatric patient under 65 years of age does not pass to the psychiatry of old age service on reaching 65 years old but remains in the service in which he or she started. This is an issue which needs to be looked into. I was interested to hear what the Minister of State said about demarcation in relation to the move from St. Loman's to Tallaght Hospital. Doctors, nurses and ancillary staff are there to provide a service. The patient and not the service should come first. Something which bedevils health services in this country and others is that they are service orientated rather than consumer orientated. We have to change that attitude. There is a continuing drop in the number of patients in psychiatric hospitals and units from 5,500 people in 1994 to 5,100 in 1997. We should not assume that because there is a decline in numbers in psychiatric hospitals there is a declining need for psychiatric services. The reverse is true. There is a need to accelerate the growth of more appropriate care facilities for persons with mental illness with further development of community-based facilities throughout the country. I welcome the guidelines and good practice in Quality Assurance in Mental Health published and circulated last year to all providers of mental health services. There are major problems facing the psychiatric services. One of the most frightening is the growing incidence of suicide and attempted suicide amongst the younger population, especially young males. I have seen at first hand the devastation that wreaks in families. It can take years for families to come to terms with it. We need, as a matter of urgency, a strategy for tackling this problem. I thank and congratulate the Minister of State on his attention to the psychiatric services and other services which are not high-profile. The provision of these services improves the quality of life of the individuals and groups who are the recipients of these services. The Minister has not sat in the ivory tower in Hawkins House since his appointment. He has gone out and seen at firsthand the problems which exist. Having seen them he has implemented an action plan to deal with them. I need only mention his visit to St. Ita's in Portrane last year which was probably the first time a Minister for Health had ever visited that hospital. He saw the actual physical conditions which pertain therein. I compliment the staff, doctors and nurses and ancillary staff who work in the psychiatric services, often under difficult and stressful conditions. They provide an excellent service. Mr. Norris: I pay tribute to my colleague, Senator Henry, for her continuing interest in this matter. She has pressed these issues for quite some considerable time. I, too, have taken an interest in this matter and in particular the case at Portrane. We were alarmed by reports on radio and in the media - and it was ventilated somewhat in this House - on this matter. I suggested that we might send a delegation from the House to visit Portrane. It never happened. I suppose I could have gone on my own. There was more rhetorical interest than physical interest at that time. I am not criticising all my colleagues. I think we can sometimes be a little cavalier about the treatment of mental illness and we can put people out of sight and therefore out of mind. We need to be honest about that. There was a very moving and haunting programme on RTE Radio last week. I do not remember the name of the programme or the name of the family involved. It was about a man, the victim of mental illness and a form of retardation. He was at home until he was seven years old and then spent time in various other places like the Augustinians in Obelisk Park and subsequently went to Peamount Hospital. The family were extremely honest and made it clear that the demands placed on them as human beings and as a family were such that all of them gradually pulled back as he got older. Senator Fitzpatrick referred to the word "asylum" and suggested that in the old days there was a very benign application of that word. I hesitate to challenge him too bluntly but when asylum started off with places like the Bedlam Asylum in London they were far from havens of peace. Mentally ill human beings were regarded as animals to be goaded into exhibiting as bizarre a form of behaviour as they possibly could as an entertainment for the middle classes. It is worth putting on record that it was Jonathan Swift, Dean of St. Patrick's, who led the way in Europe in the treatment of mental illness by leaving money to found St. Patrick's Hospital because he recognised very early that mental illness should be treated as just that. It was not possession of evil spirits or badness or something by which we could be amused. It was something that was susceptible to treatment. I regret that the Government side has decided to amend this motion. I do not see anything directly critical of offensive in the resolution as drafted by Senator Henry. She is simply calling for action. Presumably we all want action. Yet, in a regrettable knee-jerk response, the Government side has decided to amend it to an anodyne paean of praise. That will not do any good for the people at the cutting edge of this matter. We need to do something about this difficulty.

The Minister acknowledged in his speech that a problem exists. We need to know exactly what will be done about it. He said: It has been the case in the Eastern Health Board area that beds have been unavailable in some instances for patients with acute illnesses requiring hospitalisation. This has led to a system of transferring the patients for short-term purposes from one catchment area of service to another with consequent delays and disruption of patient care. I would have thought that if one were mentally unstable or feeling unwell the last thing one would want is to be shifted around from one catchment area to another. It is difficult to get a purchase on mental illness because it is difficult to quantify unless it has a measurable physical component. I think here of the words of James Joyce confronting the schizophrenia of his daughter, where he felt he was being reproved by his friends for spending money searching for a cure for what he described as the most elusive illness known to man and unknown to medicine. It is heartless, in dealing with this volatile, vulnerable area, to push such people around the country. The Minister also said that "the current provision of beds, at 0.43 per thousand of total population, is not far off the planning norm". That is fine, but there is room for improvement. It may not be far off the norm but I would like a commitment from the Minister that it would reach the norm. The Minister also referred to community based psychiatric services replacing institution based services, which would mean the planning norm would need to be revised downwards. We need to monitor these community based services to see how efficient they are, to what extent they are fulfilling the needs of patients and the extent to which these people are being made vulnerable. In America people who are incapable of looking after themselves are turfed out onto the streets, which is very heartless. The Minister went on to state: I acknowledge the existence from time to time of the problem of bed blocking by non-acute patients which results in patients being transferred, sometimes at short notice, from one service to another in order to make beds available to patients for whom admission is deemed imperative. This is another area where there is a problem. A bland, anodyne acknowledgement of the initiatives by the Government simply does not meet the circumstances of which we are aware. The Minister also said "The report states that only 53 per cent of patients surveyed received a full psychiatric assessment prior to referral for admission". I have referred to the problematic nature of mental illness, yet only 50 per cent of patients receive a proper assessment before they are admitted. That is not good enough. I received a short briefing note from the Eastern Health Board, which was sent to me by a remarkable woman I know who was held hostage last night with her husband by somebody who was mentally unbalanced. I pay tribute to her for having the resources to send this material to me. It states, with regard to the report entitled "We Have No Beds": The report details the results of a comprehensive examination of the availability and utilisation of acute psychiatric beds in the EHB area, including all non-private, adult psychiatric hospitals and units serving a defined catchment area. The study has several components: a study of bed occupancy, a study of all patients occupying acute psychiatric beds, a study of admissions over a two week period, a report of interviews carried out with over 80 per cent of consultants, an account of the spectrum of psychiatric services in each catchment area related to the population aged 15 and over and a synopsis of this information, matching provision to each, including socio-economic deprivation as an indication of need and potential demand on the psychiatric services. The significant conclusions of the report were as follows. First, an adequate number of acute psychiatric beds in the Eastern Health Board area were available but 45 per cent of them were not available for acute use. I would have thought that acute use was the use for which they were most needed. The figure of 45 per cent not being available for acute use causes me some concern. Second, a range of alternatives are required to support acute interventions at graduated levels. These alternatives include: rehabilitation places, community based continuing care residences, a spectrum of services including hostels, day hospital places, community mental health care teams within catchment areas to meet assessed needs, crisis intervention, domiciliary and home care, response to alcohol problems, the need for referral at short notice, homelessness [which is a really severe problem], access to community residential places and psychiatric intensive care units. The report stated that, in regard to technical skills, a range of professionals is required to meet needs. The policy areas were defined as the functions of a day hospital - to which I have already referred - the purpose of community health care teams and agreement on the admit/discharge policy, which is a very sensitive area. Another policy area is the making of decisions to admit. The decision is mainly made by junior doctors, with only one-third of admission decisions made by consultants. As I said earlier, 53 per cent of patients are assessed prior to referral. Some 48 per cent of admissions are made between 6 p.m. and 8 a.m., which is an interesting statistic as it seems it is a night time phenomenon. The report also found there was considerable socio-economic deprivation in the Eastern Health Board area. The small area health research unit found in 1997 that areas 4, 5 and 6 were the most deprived and area 1 was the least deprived. I am glad to say I think I live in area 1. The recommendation of the board stated: The report is welcomed by our board and will be invaluable in terms of future planning of services for our board's area. At present, we are formulating a five year strategy for the future development of mental health services in our region and the conclusions of this report will be taken account of in the planning process. It is proposed to make a detailed presentation of the report's analysis and conclusions at a future meeting of the programme committee on health promotion, mental health, addiction and social development. I hope and trust this report will then be placed before the House. It is a pity this motion has been undermined by an unnecessary amendment. I was challenged the other day by some of my friends in Fianna Fáil who asked me why I never show my independence by voting with them. I pointed out that I had done so on a number of occasions but I only do it on principle. On principle, I will be voting this evening with my esteemed colleagues Senators Henry and Jackman. Mr. Glynn: Cuirim fáilte roimh an tAire. It is imperative to acknowledge that, while the psychiatric services are not in a utopian state, significant improvements have been made, which is the motivation behind the amendment. I worked in the psychiatric services for many years. I compliment my colleague, Senator Henry, for tabling this motion and I am sure she will take our amendment in the context I have outlined. I share her concern about the abuse of the psychiatric services. She asked me the other day if I had seen the report and since then I have read it and taken some of the salient points from it. The problem is not really the shortage of psychiatric beds but the abuse of the services. The psychiatric service is the most abused acute service in the health services. The hospital in which I worked for many years would be used on more than one occasion during the week - sometimes twice in the one night - not as a hospital but as a hostel, which was outrageous. An individual, usually accompanied by the gardaí, would present themselves loaded to the gills with drink and the night nurse would have to let them in. A nurse would have to be borrowed from another centre and sent with them to a different location. Not only would they waken all the patients but they would give the nurses abuse. If they stayed the night, they would get a healthy breakfast the following morning and then leave. This happens on an ongoing basis. I am not surprised at the statistics on inappropriate bed occupancy. Psychiatric hospitals are being used for the homeless. In the hospital in Mullingar where I worked, patients were often admitted at 2 a.m. or 3 a.m. by the gardaí who did not know if they had been patients at the hospital before but who had nowhere else to bring them. This is an outrageous abuse of acute psychiatric beds. In the past psychiatric hospitals were used by certain elements of society when a member of their immediate or extended families became psychiatrically ill. They were admitted as a temporary patient on what we called the pink form and their case would be reviewed after six months. The Minister said there must be regular clinical reviews. I am glad the consultants who worked in the acute unit of the hospital in which I worked carried out a review every day. It was the responsibility of the nurse in charge of the dormitory or the clinical nurse to advise the consultant on the progress or lack thereof of an individual. This meant there were ongoing clinical reviews, which was important. There is a strong incidence of psychiatric illness among farmers who are bachelors or spinsters as they approach 50, 60 or 70 years of age. A contributory factor is loneliness so it is imperative that families support them. Senator Jackman referred to secure units. It is important for two or three health boards to liaise with each other and to provide one secure unit. Many patients cannot be treated in normal psychiatric acute units because of the nature of their illnesses. Something must be done about this. Alcoholism was also mentioned. Psychiatric acute units are used as detoxification units. I have experience in this area as I did an alcohol therapy and substance abuse course some years ago. A bedded unit was initially provided in the Midland Health Board area but it then decided, and I agreed with it, to disband it. Detoxification now takes place in the hospital and the programme is done in the community. If a person is not motivated to do that programme in the community, they have no intention of giving up alcohol. I welcome the development of community based residences which are the result of planning for the future. It is imperative that psychiatric patients, particularly those participating in the rehabilitation process, are not allowed to vegetate in any one area. They must be moved from one place to another and given new challenges. The low, medium and high support residences are playing a pivotal role in helping to plan for the future of the psychiatric services. There are 52 males and 35 females in the Westmeath and Longford catchment areas. There are three days centres in Athlone, Mullingar and Longford and two respite beds will be provided. The objective of the exercise is to keep patients away from the hospital. When I entered the psychiatric services there were almost 1,200 patients in St. Loman's Hospital in Mullingar; there are now fewer than 300 and it is decreasing. I remind those who plan for the future of the psychiatric services that the duty of nurses and doctors is to get the patient back into the community. That has helped in my health board area. Reference was made to acute psychiatric units attached to general hospitals. Some 50 beds will be provided in the acute unit of Portlaoise General Hospital in the Midland Health Board area. A 50 bed unit will also be provided under phase 2B of Longford-Westmeath General Hospital in Mullingar. There are 0.5 short and medium stay beds and 0.2 new and long stay beds per 1,000 people under 65 years of age and 0.3 beds for those over 65. This works out at approximately one bed per 1,000 people. The 50 bed units in the locations I mentioned are the accepted norm. This will only work if community services are developed in tandem with acute services because one complements the other. The community service is better for patients and staff but it is more expensive. It is imperative that recruitment to the psychiatric nursing profession continues because it has dropped in recent years. There was a time when thousands of people tried to get into the profession but that has changed and it is causing problems. Something should be done to recruit appropriate staff because services are not what they used to be. Psychiatric hospitals were not built as treatment units. Reference was made in the report to suicide. The length of the wards in psychiatric hospitals are so long a psychiatric nurse looking after depressed people would need to be Ronnie Delaney to make it from one end of the ward to the other to prevent someone from harming themselves. I would need two days to discuss this very important issue. Dr. Henry: I thank my colleagues who contributed to this debate, particularly Senator Glynn. I wish we had two days to listen to him as we could learn an enormous amount from his practical experience in this area. I am glad Senator Norris referred to Dean Swift. It is very sad that in a city in which the innovative St. Patrick's Hospital was founded more than 250 years ago for fools and mad people, greater emphasis is not placed on really improving psychiatric services in Ireland. I regret to inform Senator Norris that although he may live in the Dublin 1 postal district, he is in the Dublin 6 catchment area for the purpose of psychiatric services, which is one of the worst - although Dublin 4 and 5 are also pretty bad. Mr. Norris: The Senator should have completed Swift's phrase: He left what little wealth he had to found a home for fools and mad, and showed by one satiric touch no nation needed it so much. Dr. Henry: Perhaps Senator Norris could start some local action groups in his area. The last lines of the Minister's speech enlightened me on why the amendment had been tabled. He states: "For my part, I remain fully committed to the continuation of the pace of development of services...". That is worrying because the pace of development of services is remarkably slow. The Minister referred to acute bed units being set up in general hospitals in the not too distant future. I recall when Planning for the Future was published almost 15 years ago. We thought the beds would come on stream in a matter of a few years. I dread to think how long it will be before St. Loman's gets to Tallaght. The Minister quite correctly referred to the inflexibility of many of those involved in the profession in which Senator Glynn and I work. Flexibility can be important in the transfer of patients. The Minister will have to face up to people. I spoke about my approval of his actions in regard to the manpower forum and getting consultants to work more flexibly. If people have to take jobs where they are needed at certain times, so be it. The same applies to the accident and emergency services. It is not a question of what is best for the taxpayer or the service, rather what is best for the patient. If it is best for the patient, those of us in the so-called caring professions will have to adopt more flexible working conditions. Many Senators stated that society does not really know what to do with psychiatric patients, it shunts them off to psychiatric hospitals for want of somewhere better to send them and it is really quite pleased once they are out of the way. That is something we will have to face up to. It is very difficult to create any interest in psychiatric services; the Minister will not lose any votes if the service does not change rapidly. The people who are ill will not be voting for him, and their families, as Senator Norris stated on the radio, often try to put the matter out of their minds because it is so upsetting. I am delighted to hear that the mental health Bill will be introduced in the next session. Something dramatic must have happened in the Office of the Attorney General because we have been informed the Bill has been there for a year and a half. Senator Glynn will be aware of the grave difficulties encountered due to the 'person of unfit mind' forms. Doctors have been sued on numerous occasions for admitting people to hospital on these forms and psychiatric nurses have refused to go out on calls to bring in patients who are a danger to themselves and others. These patients are being brought into hospital by the gardaí who should not be doing that. The situation is very serious and I hope the Minister is serious about addressing it. I look forward to the next session which I presume will end some time in July. I dread terms such as "the near future" or "by Christmas" - which begs the question, "which Christmas?". I look forward to the publication of the mental health Bill as the existing Act is 55 years old and the treatment of psychiatric patients has changed dramatically over that time. It is essential that the legislation changes also.

Amendment put. The Seanad divided: Tá, 25; Níl, 17.

Tá

Bohan, Eddie.

Callanan, Peter.

Cassidy, Donie.

Chambers, Frank.

Cregan, John.

Dardis, John.

Farrell, Willie.

Fitzgerald, Liam.

Fitzgerald, Tom.

Fitzpatrick, Dermot.

Gibbons, Jim.

Glynn, Camillus.

Keogh, Helen.

Kiely, Daniel.

Kiely, Rory.

Lanigan, Mick.

Leonard, Ann.

Lydon, Don.

Mooney, Paschal.

Moylan, Pat.

O'Brien, Francis.

O'Donovan, Denis.

Ó Murchú, Labhrás.

Ormonde, Ann.

Walsh, Jim.

Níl

Burke, Paddy.

Caffrey, Ernie.

Coghlan, Paul.

Connor, John.

Coogan, Fintan.

Cosgrave, Liam T.

Costello, Joe.

Cregan, Denis (Dino).

Gallagher, Pat.

Hayes, Tom.

Henry, Mary.

Jackman, Mary.

McDonagh, Jarlath.

Norris, David.

O'Dowd, Fergus.

O'Toole, Joe.

Ridge, Thérèse.

Tellers: Tá, Senators T. Fitzgerald and Keogh; Níl, Senators Henry and Norris.

Amendment declared carried.

Motion, as amended, agreed to.

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