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.

 

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

  1. Paediatric liaison services and models of care are well placed for a number of the points you raise above; increasing access to mental health professionals for the socially vulnerable who often tend to present via ED (and repeatedly), raising access for the groups of children who fall between services in CAMHS or Paeds as they present with physical or medically unexplained symptoms or long term conditions and being well placed to teach,train and promote prevention in non mental health settings. The liaison model at the Whittington hospital where I work (mdt, consultant led, therapeutic focus, and commissioned and embedded within Paeds not CAMHS) has many strengths. Often people don’t understand the nuances of service differences between CAMHS and paediatric liaison so it’s one you might helpfully point out at the meeting also.

  2. Long term planning for our youngsters who have a diagnosis of autism accompanied by mental health issues is non-existent. We are constantly told that ‘the problem is their autism’ therefore there is no answer but to go home and attack mum or become so depressed you don’t leave your room. This, despite the fact that we know the needs so well and see them repeated so often. More training for teachers and all school staff would help absolutely but teachers cannot be everything to everyone, especially everyone in crisis. Reviewing school exclusions would be a great start. The third sector offers huge amounts of the ‘care’ you describe but is frequently forgotten in planning and when remembered is often expected to offer high levels of professional care on the cheap. Parent ‘training’ is woefully inadequate and may be seen as an even cheaper alternative to anything else. Interesting that where teams of qualified staff, working shifts fail we send children back home often to a lone parent to manage. None of this is magic or rocket science but there is a cost and it does mean breaking down the division between children and adult services or children, transition and adult services, which now seems to have just created a third place for delays and lost papers, rather than smoothed the path as we all hoped. Health, Social Care, Third Sector all of us have a role but the answer for some of our most vulnerable children is in excellent and long term planning that is resourced properly with immediate pathways for crisis intervention when all else fails. We know some of the answers but sadly politicians hold the purse strings.

  3. I agree entirely with the points you raise but wish to mention the importance of the needs of children with a learning disability. They are an often forgotten group and future in mind and the CYIAPT programme barely mention them. Yet Autism and LD are the commonest causes of disability in childhood and associated with increased rates of behavioural and emotional problems as well as increased risk of significant mental health problems.

    There are few comprehensive community child LD teams in the country, even fewer inpatient services that will admit them if needed and many CAMHS services either don’t see them or if they do don’t know what to do with them.

    They area also more likely to be abused and end up in care..

    Even more children have learning difficulties and if they have behaviour problems are in the difficult position where neither LD services nor CAMHS will see them.

    Rates of these are increasing with the increased survival of pre-term babies and the growing problem of not just Foteal alcohol syndrome but also foetal a alcohol spectrum disorder.

    Any future plans must include these important but neglected groups of children and young people and their families and careers.

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