The government’s green paper on CYP mental health looks a lot like a white wash.

At this point, everyone agrees that children and young people’s (CYP) mental health services are in crisis. So we all gave a wary cheer when a green paper was announced last year. Just before Christmas it emerged and…. well.

The challenge facing the government is, admittedly, immense. Only 25% of CYP with a mental health problem receive treatment from specialist services, suicide is the 2nd biggest killer of adolescents, and the mental health problems in adulthood that represent our single biggest health problem (more than cancer, heart disease et al) mainly start in these years.

There are two ways it could have gone. The DH could faced up to the crisis, and the fact that you’re not going to quadruple the size of specialist services (even if you had the money, you don’t have the people). They could have looked beyond a simplistic, linear view of mental health as a line from ‘OK’ to ‘a bit sad’ to ‘really sad’ to ‘ill’, and realised that mental health is complex in ways that cuts across organisational boundaries, that usually doesn’t fit into neat treatment categories, and is more likely to present with anger and disruption that sadness or worry.

They could have paid proper attention to the various reports over the last decade which have pointed out the fragmentation of the system (CQC 2017) the need for meaningful collaboration between agencies locally and nationally (Lenehan 2017, Future in Mind 2015), and that CYP mental health needs to be actually, properly, everyone’s business (Basically every report ever).  They could have injected resources into the system while creating the legislative structure to pull agencies together into the kind of collaboration we need.

But they took the other approach, that of the PR professional, who asks ‘who are the loudest voices, and how can we get them onside?’. From this point of view, the fact that the linear view of mental health as ‘sadness and worry’ is so wrong doesn’t matter, because it’s the media view. The fact that the most common condition in mental health, conduct disorder, is barely discussed is quite convenient because it’s complicated to treat and mainly happens to poor people. And the fact that schools are loudly banging the mental health drum becomes an opportunity.

What the DH need is to be seen to do something- they need a headline, and they need visible services that will please schools. So they will embed mental health workers in schools who will pick up the low-level sad/worried pupils, and give them a brief psychological intervention. No matter that we don’t know if this model works, how many of these cases would be self-limiting anyway, how on earth schools will ensure quality or governance, or how it will connect to the wider system. It will allow the government to claim huge figures of young people ‘treated’ and allow everyone to feel better about themselves.

But I’m being slightly unfair. These teams will also, it seems, run parenting course. I’m all for that, but it doesn’t really help unless you also have a service that can assess children’s behaviour and see what underlies it. And there are no extra resources for this, so what happens if the parenting course doesn’t help? “The parents aren’t doing it right”.

This is a disappointingly narrow, shallow, and headline-chasing response. There is no mention of wider child health services which provide support for autistic children, those with ADHD, children with special needs, looked after children etc, there is scant reference to wider vulnerable groups, and the connections between physical and mental health are ignored. Above all, there is zero attention to reversing the fragmentation of local systems. It’s not even as if the model suggested it that cheap- estimates are circulating that they will need to employ 8000 people, more than currently work in specialist CYP mental health services now!

The frustrating thing is that the green paper could be much better with just a bit more attention to the system as a whole– better guidance for commissioners, money in the system as a whole and a duty for all local agencies to spell out their contribution to a ‘local offer’ for mental health, which the local population can interrogate and influence, will do so much more than the sticking plaster on offer.

But it’s still just a green paper. It can change, right? Well, yes, but so far the DH have been amazingly bad at engaging with the sector about this, and time is running out. Pressure is required to get them out in the open- more pressure is needed to see that a good headline and some happy headteachers isn’t going to make the problem go away.

 

Advertisements

Doin’ it for the kids

Single issue voting had a bad press, perhaps because people find it odd that someone would align themselves politically according to whose policy on local parking is most to their liking, or whatever. But I’ve realised in this campaign that I’m a single issue voter, more or less, but my issue is children.

Partly this is professional. I’m a paediatrician, and so very aware of the impact of social and economic factors on children’s well-being. I know, for instance, that child poverty is a huge driver of ill health, both physical and mental, and that the removal of much of the early intervention safety net (such as health visiting and sure start) has been a disaster for families who are already struggling.

But the issue is also about schools, who are simultaneously squeezed financially, and pushed into being dour exam factories, making them rapidly less healthy places to be.

And it’s about families- most people have found the last few years tougher and tougher, with merciless cuts to working age support and stagnating wages, and all this stress and disruption will eventually find its way to kids.

Of course, as we are constantly reminded, support for the vulnerable relies on a strong economy, and there are genuine disagreements about the balance between balancing the books by restricting funding, and investing for growth (although the last 10 years gives a pretty convincing case for the latter).

Wherever you stand on this, though, presumably you don’t feel we can afford the £66bn cost of Brexit... oh, you think we can?  Then presumably a few quid for better child services might not be beyond us? After all, either you want to pay down the debt, or you don’t.

Finally, there’s no point supporting children through the early years to hand them a world ravaged by the climatic, political and humanitarian catastrophe that climate change will turn into unless we act now.

So, we need politicians willing to swallow pride over Brexit, reduce child poverty, ensure decent services, release pressure on schools, genuinely support those ‘just about managing’, and stand up to the troglodytes opposing climate change.
Which party? Well, that’s up to you, but I can think of a couple that this checklist really counts out…..

Who speaks for the bad boys (and girls)?

In a way, we are in a golden age for attitudes to young people’s mental health. Just this week, no less a figure than Prince Harry talked about his own help-seeking, both he and his brother and sister-in-law have campaigned for better services and more positive societal attitudes. Theresa May has discussed the issue in a not-entirely-bad speech.

But what if I was to ask you what the most common mental health condition is in the UK? Most people guess at anxiety, or depression. If pushed they might go for eating disorders. But it’s none of these. By a considerable distance, it’s conduct disorder.

Conduct disorder is, roughly, an established and disruptive pattern of anti-social behaviour, which impairs the young person’s life. The commonest objection is that this is not really  a mental health disorder, but that in itself betrays quite a restrictive attitude to what emotions and thoughts we regard as worthy of help, and which we reject and condemn.

Imagine two girls of 14.

One, Amelia, is lonely and sad a lot of the time, she doesn’t think her friends like her, and self-harms by cutting her forearms.

The other, Charlie, is angry and alienated. She thinks her mum hates her and they row a lot, and she self-harms by drinking in the park and getting into fights.

Which girl is more worthy of our concern and care? I would argue that they are both, equally worthy of our compassion and to receive the help that they need.

However, the narrative around mental health is exclusively about the type of problems that Amelia has, and puts Charlie in the ‘broken Britain’ bin of delinquents and ‘problem families’. And it isn’t just the media- I’ve been to discussions of young people’s mental health at the Department of Health, NHS England, the Royal College of Psychiatry and innumerable charities, think tanks and parliamentary groupings. I have never seen a young person with conduct problems attending, and no-one (other than me) has ever, ever mentioned this condition which, just to remind you, is the most common mental health condition in young people. When I do mention it, everyone nods, mumbles, and goes back to what they were talking about. Usually mindfulness, or apps.

Why is this? It’s not because people in the field are stupid, or uncaring.

One problem is that these kids do not have socially acceptable mental health problems. They are routinely rude, they often undermine attempts to help them (mainly because they don’t believe they are worth helping). They are not eloquent, typically, and are often ashamed of their feelings in a way that we encourage with our condemnation.

One big focus in mental health has been the role of schools in supporting pupils with mental health problems, but hand in hand with moves to train every teacher to deal with anxiety and depression is a hardening of attitudes to anything remotely anti-social, and the return of the disciplinary culture of the 1950s will do far more damage to mental health than any amount of amateur CBT can compensate for.

Anxiety and depression are, demonstrably, no respecters of social class. Conduct disorder, on the other hand, very much is- it is vastly more common in poorer families, and so society’s attitudes to poor families are transferred to their troubled offspring.

The help they require is complex, and requires co-ordination across multiple agencies, support for the whole family, and above all, patience. They can be helped, and there is a lot of evidence of effective interventions, but ultimately they are too difficult, and give too little political reward, to be the priority.

Conduct disorder is associated with every kind of negative outcome you can think of. It is a major, treatable, public health problem. Why are we not talking about it?

Does Theresa May actually care about the CAMHS crisis? If so, here’s what she needs to do

 

On the 9th January, Theresa May made a good(ish) speech. She talked about injustice, and about how peoples’ opportunities are too conditioned by their position in life. She then turned to children’s mental health and talked about the train-wreck that is current provision.

What did she suggest?:

  • A review by the CQC
  • Teachers to be trained in mental health first aid.
  • An end to out of area transfers (but only for ‘general mental health’ so won’t mean anything)

Now, for the issue to get prime ministerial attention is a good thing, no doubt. But how much difference will it make, really?

Let’s look at the situation. 850,000 children have a diagnosable mental health problem in the UK, of which only 25% receive a service from specialist CAMHS. The plan from NHS England is for the recent cash injection to increase this figure to…. 33% by 2020. This assumes that the money is getting through, which it pretty clearly is not. It also raises the question- even if you do manage this increase, what about the other 67%?

This is where Mental Health First Aid comes in. The idea is that teachers pick up the early signs of emotional distress and put in place simple measures, thus stemming the flow of referrals to specialist services. There are two problems with this: one is that there is no evidence that it does any such thing, and the second is that it’s only dealing with what I call socially acceptable mental health.

What is the most common mental health problem among the 850,000? Anxiety? Depression? No, it’s conduct disorder, broadly, a pattern of disruptive behaviour leading to significant impairment. These kids often have complex social, biological, psychological and educational aspects to their stories, and need complex, multi-agency intervention to get better. But the point is they CAN, but they are too tricky, and not good at advocating for themselves, and are much easier to shunt into the youth justice system. And they are HALF of the 850,000 with diagnosable problems. People talk about universal parenting course access, but anyone who works on the front-line knows that these are no panacea.

The rest of the 67% will be kids who don’t have straightforward mental health presentations- those with autism, ADHD, learning disability, or traumatised children who are too angry and fearful to look sad.

So what is needed? What should we say when CQC comes to call? Apart from handing them copies of the other three CAMHS reviews completed in the last 2 years?

You’re never going to get 100% of eligible children into specialist care, and actually you may not want to- what a lot of them need is broader, more complex and more long-lasting than a block of therapy with CAMHS. So firstly, we need to expand what we mean by mental health help, and embed it into local systems.

This will require:

  • clear commissioning of a ‘local offer’ for mental health
  • Support from local specialists for the rest of the sector, in terms of consultation, training and joint work.
  • A children’s workforce who understand mental health and the many ways of helping.
  • Inspection of what the local area provides for children’s mental health and wellbeing.
  • Training and guidance in best practice across the sector.

Second, we need to ‘shift the curve’ on mental health- by improving overall mental health we can decrease the number of children requiring care. The government are still, officially, committed to a ‘life chances’ strategy, and that sounds a lot like what Theresa May was talking about- the problem is that she was talking about adult employment, and income, rather than what really matters, which is  getting the best start by:

  • ensuring adequate incomes
  • improving early education and care
  • improving homes and environments
  • creating a truly inclusive education system that cares about more than exam results.

Is this ambitious? Sure. Is it possible? With the right political will, both nationally and locally, and engagement from professionals, yes, at least in part.

And the alternative is just leaving the 67% to fester into the next decade’s ‘problem families’.

What next for children’s mental health care? (update of old post)

Pretty much every week, we get a report lacerating our care of children and young people with mental health problems. This time, the Royal College of Psychiatrists have concluded that services are inadequate in the vast majority of areas, earlier this year Youth Access pointed out the level of unmet need, as did the NSPCC. And, as always, the government responded with two things. The ‘historic’increase in funding, and the reform programme instigated by the ‘future in mind’ report.

Let me take these in turn. The increase will, by 2020, have restored funding for CAMHS (child and adolescent mental health services) to around 2010 levels. So a historic rise will follow an unprecedented fall. In any case, given that the money is not ring fenced, or in fact new money at all, there is evidence that it’s not reaching CAMHS at all in many areas.

But even if this money got through, it’s not enough to serve the need using our current model. The consensus is that only about a quarter of young people with a mental health problem get specialist mental health care, and that’s with everyone currently in CAMHS working flat out, so you’d either have to quadruple funding, or make everyone work four times faster, to serve the population need.

But doesn’t ‘future in mind’ offer a new vision for CAMHS? Yes and no. It’s a strange document, and I say that as someone involved in writing it. On the one hand it sets up a very efficient ‘engine’ for specialist CAMHS to give time-limited, evidence based intervention via the CYP IAPT programme. It talks a lot about counselling in schools.But outside of this, it offers mainly aspirations and wishful thinking.

The reason this is a problem is not because CYP IAPT is a bad programme. For delivery of specific interventions for specific problems, it’s great. But at present it only really addresses mood disorders and offers parenting courses. Add to this the clear guidance and increased funding for eating disorders, the focus on counselling in schools, and the increased resources for inpatient CAMHS, and it’s easy to see the groups that may, eventually, do well. Broadly, it’s adolescents presenting with anxiety, sadness and anorexia. This is, in many ways, a great thing. But it’s not enough.

Most people reading this will be aware of the much used statistic that shows that 10% of children have a diagnosable mental health problem. It’s not well known, and needs to be, that half of this number have not mood disorders, but various degrees of conduct problems, in other words, behavioural problems. This group have been almost entirely airbrushed out of the picture. Also, in practice, young people whose mood problems are mixed in with social vulnerability and special educational needs usually cannot access IAPT effectively. Add in children with mental health problems presenting either as physical symptoms, or in the context of chronic conditions, and you can see that a broader vision is required.

Another thing has struck me recently. When you talk to someone who had, for whatever reason, a troubled youth, from which they recovered, treatment does figure, but care is so much more important. What I mean by this is someone, be it a parent, a teacher, a youth worker, whoever, consistently holding the person in mind, and looking out for them, consistently and unconditionally over a period of time. It’s not at all clear that the new IAPT engine is very good at this sort of care. And, in the words of one senior civil servant, it’s ‘the only game in town’.

So we have a paradox. Everyone thinks that only specialist treatment counts as help- for example the Centre for Mental Health present delays in accessing CAMHS as ‘children with mental health problems wait a decade for help’.  There isn’t enough specialist treatment for everyone, there can’t be, and the services that exist are narrowing themselves into particular areas. But what actually helps long term is care.

Is care enough? Sometimes clearly not, but if informed by adequate training (of professionals or parents), integrated across agencies and informed by advice from, and consultation with specialists, then really very often difficulties can be contained outside specialist settings. However, because parents and professionals feel disempowered, opportunities are lost waiting for a magic cure that, more often than not, just isn’t there.

We need badly to empower parents, non-CAMHS professionals, and young people themselves to be able to support these needs in the long-term.

So we need specialist treatment services, but only in the context of a wider local mental health support system. I can’t give you an immediate blueprint for this, but here are some ideas:

  • Mental health to be taught in schools as part of compulsory PHSE
  • Universal access to parent training and support.
  • All local health and well-being boards to have responsibility  for promoting cyp mental health
  • Commissioning budgets pooled across health and local authorities to prevent duplication and gaps in provision.
  • A ‘local offer’, analogous to the local special educational needs offer, developed as an extension of current transformation plans.
  • CQC/OFSTED inspection of local CYP mental health systems, focusing on collaboration and prevention
  • Improve information sharing by changing professional cultures and putting parents in charge, using informed consent to bypass restrictions.
  • Appropriate mental health training for all professionals working with children, building on the work of MindEd.
  • Local, funded strategic networks including parent and young people, as well as voluntary sector, monitoring the offer and promoting accountability for services.
  • CAMHS specialist services to be funded to provide consultation to other agencies locally.
  • Work undertaken to adapt NICE guidance to educational settings e.g. for conduct problems.
  • Schools exclusions guidance examined to ensure that all pupils are properly assessed for underlying difficulties before permanent exclusion.

 

There is work progressing in some of these areas- NHS England will be coming out with guidance on access to mental health care, and RCPCH will be pushing the ‘local offer’ idea. Watch this space.

 

The dangers of letting people become faceless

I’ve been thinking about the EU referendum campaign, and the failure of the remain campaign to counter the emotional tug of the (illusory) freedom offered by leave. They had the facts, the experts, but still they lost the battle of hearts.
There’s obviously no single reason for this, and no doubt books are already being written to explain it, but the one phrase that keeps coming back to me is ‘faceless bureaucrats’. Remain seemed to have let this trope into the conversation unchallenged, and I can’t help wondering why.
If someone is faceless, they lose their individuality, and become part of a process, humanity subjugated to the needs of the organisation they serve. There’s also a suggestion in the phrase that they are hiding, unwilling to be accountable and ‘face’ the people whose lives are affected by their decisions.
As far as I am aware, no representative of the EU ever publicly faced questions from the British public. Why didn’t Remain arrange this? Possibly, of the several thousand people employed by the EU, none of them had sufficient communication skills to face a hostile audience? Seems unlikely. Perhaps Remain were terrified of allowing a ‘foreigner’ to participate in ‘our’ debate, but isn’t that just playing into the narrow agenda of Leave?
There would have been risks, but if they had found someone fresh, persuasive and optimistic about Britain’s place in Europe, who is also a ‘bureaucrat’, it may, just, have challenged the damaging, dehumanising rhetoric of facelessness.
We’re all guilty of it, at times. When I get an email from management that annoys me, I chunter at the ‘bloody management’. But the email wasn’t written by management. It was written by a person, as I discover when I get off my high horse and bother to talk to them.
Of course, there are far more damaging forms of dehumanisation, and you only need to glance at social media to see both sides vigorously peddling stereotypes about the other.
But when campaigning for a cause, often the first thing we reach for is a human face- the most striking recent example of this being the refugee crisis. The Remain campaign’s failure to give the EU a human face played into the hands of its opponents, and was therefore a political, as well as moral, failure.