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.

Does excess folate cause autism? Not even close.

Quick one this, I’m rushing out and this just appeared:


Too much folate in pregnant women increases risk for autism, study suggests

Researchers say that while folate deficiency is bad for developing fetus, excessive amounts could also be harmful



Women who plan on becoming pregnant are told they need enough of the nutrient folate to ensure proper neurodevelopment of their babies, but new research from the Johns Hopkins Bloomberg School of Public Health suggests there could be serious risks in having far too much of the same nutrient.

The researchers found that if a new mother has a very high level of folate right after giving birth – more than four times what is considered adequate – the risk that her child will develop an autism spectrum disorder doubles. Very high vitamin B12 levels in new moms are also potentially harmful, tripling the risk that her offspring will develop an autism spectrum disorder. If both levels are extremely high, the risk that a child develops the disorder increases 17.6 times. Folate, a B vitamin, is found naturally in fruits and vegetables, while the synthetic version, folic acid, is used to fortify cereals and breads in the United States and in vitamin supplements.

The findings will be presented May 13 at the 2016 International Meeting for Autism Research in Baltimore. A press conference is scheduled for 10 a.m. on May 11 at the at the Baltimore Convention Center, Room 302-303.

“Adequate supplementation is protective: That’s still the story with folic acid,” says one of the study’s senior authors M. Daniele Fallin, PhD, director of the Bloomberg School’s Wendy Klag Center for Autism and Developmental Disabilities. “We have long known that a folate deficiency in pregnant mothers is detrimental to her child’s development. But what this tells us is that excessive amounts may also cause harm. We must aim for optimal levels of this important nutrient.”

Folate is essential in cell growth and promotes neurodevelopmental growth. Deficiencies early in pregnancy have been linked to birth defects and to an increased risk of developing an autism spectrum disorder. And despite this push to ensure women get adequate folate, some women still don’t get enough or their bodies aren’t properly absorbing it, leading to deficiencies. The Centers for Disease Control and Prevention says that one in four women of reproductive age in the U.S. have insufficient folate levels. Levels are not routinely monitored during pregnancy.

Autism spectrum disorder is a neurodevelopmental condition characterized by social impairment, abnormal communication and repetitive or unusual behavior. One in 68 children in the U.S. have the disorder, with boys five times more likely than girls to have it. The causes remain unclear but research suggests the factors are a combination of genes and the environment.

For the study, researchers analyzed data from 1,391 mother-child pairs in the Boston Birth Cohort, a predominantly low-income minority population.

The mothers were recruited at the time of their child’s birth between 1998 and 2013 and followed for several years, with the mother’s blood folate levels checked once within the first one to three days of delivery. The researchers found that one in 10 of the women had what is considered an excess amount of folate (more than 59 nanomoles per liter) and six percent had an excess amount of vitamin B12 (more than 600 picomoles per liter).

The World Health Organization says that between 13.5 and 45.3 nanomoles per liter is an adequate amount of folate for a woman in her first trimester of pregnancy. Unlike with folate, there are not well-established thresholds for adequate vitamin B12 levels.

A large majority of the mothers in the study reported having taken multivitamins – which would include folic acid and vitamin B12 – throughout pregnancy. But the researchers say they don’t know exactly why some of the women had such high levels in their blood. It could be that they consumed too many folic acid-fortified foods or took too many supplements. Or, they say, it could be that some women are genetically predisposed to absorbing greater quantities of folate or metabolizing it slower, leading to the excess. Or it could be a combination of the two.

More research is needed, the scientists say, in order to determine just how much folic acid a woman should consume during pregnancy to have the best chance that she will have optimal blood folate levels to ensure her offspring’s health.

With many types of vitamin supplements, the conventional wisdom has been that too much is not harmful, that the body will flush out the excess. That may not be the case with folic acid and vitamin B12.

“This research suggests that this could be the case of too much of a good thing,” says study lead author Ramkripa Raghavan, MPH, MSc, a DrPH candidate in the Department of Population, Family and Reproductive Health at the Bloomberg School. “We tell women to be sure to get folate early in pregnancy. What we need to figure out now is whether there should be additional recommendations about just what an optimal dose is throughout pregnancy.”

In summary: FFS

In more detail:
If the study had shown a causal link between excess ingestion of folate and B12, this would be an extraordinary finding. It would therefore require extraordinary evidence.
However, this study only shows an association, which may be due to chance, reverse causation, or a common unknown factor causing both an increase in ASD diagnosis, and B12/ folate levels.
The study might appear to be large and well-powered, and it is hard to comment without the data, but I would estimate that you are talking about the difference between (roughly) 104 out of 1250 ‘low folate’ women having children with ASD, versus 3 out of 140 women with ‘high’  folate, when one would expect 1 diagnosis in for this number. So you are essentially talking about 2 extra diagnoses, which in a complex spectrum condition like ASD is impossible to interpret as anything other than chance.   The figure of 17.6 for having both high folate and B12 is literally meaningless.
So even on the basis of their data, which has not been peer-reviewed, the authors are going way out on a limb in drawing casual connections here, and are being quite irresponsible in undermining decades of public health work to increase the numbers of women taking folate before and during pregnancy, in order to prevent potentially devastating neurological conditions.

Life after Jeremy

I remember when Jeremy Hunt was seen as the pragmatic, non-ideological alternative to Andrew Lansley. But since the junior doctors dispute blew up, he appears to have lost his political marbles.
He’s never really understood health, but as long as he kept quiet that didn’t matter too much: Lansley had disconnected the levers connecting Whitehall to the front line anyway. But since the dispute has forced him out in the open, his lack of understanding and respect for the complicated and messy business of healthcare has been exposed. His latest outburst about Googling children’s rashes is just the culmination of months of cloth-eared pronouncements.
For a while on social media, the more forthright medical types have been calling for him to resign. I doubt this will happen, but there seems a good chance that he will be reshuffled away, given that doctors’ loathing of him is now a significant barrier to resolving the dispute. But would whoever comes in be any better?
I hate to break it to people, but the new health Secretary would still be a Tory. Let’s say for the sake of argument that Nicky Morgan is moved from education, which seems the best guess given how well she cleared up Gove’s mess.

She would still be operating within a stagnant funding envelope, with rising demand and a manifesto promise of 7 day services. She won’t get more money from the treasury. She could try to drive public health, prevention and self-care up the agenda in order to limit growth in demand, but that takes years to bear fruit, and Hunt’s rash debacle shows how careful politicians have to be when taking work away from doctors (clue: they don’t like it).

So she needs to finesse the 7 day services issue. In one sense this seems possible- by making it clear that she’s only interested in safety at the weekend, not convenience, she can neutralise a lot of medical opposition to the plan. She might then be able to work with the Royal colleges and other organisations to come up with a plan.

Unfortunately, this may not help the juniors. Their hospital work is primarily about acute presentations, and with GP imploding, inevitably the NHS will need a lot of them at the weekends. Of course we could re-shape funding, sort out primary and social care and train other professionals to take on wider roles (but remember about taking work away from doctors…): all these laudable things take time, and Morgan will need bodies on the ground to keep things moving. She can’t do this without making weekend staffing cheaper, overall.

So Jeremy may well go in the spring… but having helped to remove him, the juniors might benefit least from his demise. Which is kind of typical.

An excellent addition to the debate on video games and behaviour

Pete Etchells and Suzie Gage are two of the most knowledgeable and level headed people to read about the fevered issue of video games and children’s behaviour, so I’m really pleased that they have produced a cracking paper on the subject. 

This paper uses the best available data to place the debate around video games and behavioural problems on a scientific, evidence-based footing.

In doing so, they have busted some important myths. The overall amount of games played is not associated with adverse outcomes. The association between violent games and behavioural problems is weak, and only possibly causal.

We know that all children play games. As a developmental paediatrician,  the families that worry me are those that are unable to set boundaries about what games are appropriate, leading to exposure to 18 certificate games. However these are also families who struggle to set boundaries more generally. This is itself associated with later behavioural problems including conduct disorder, and may be one of the residual confounders mentioned by the authors. In other words, exposure to violent video games at 8 might be a marker of deeper problems, as much as a contributor to them.

So rather than scapegoat video games generally, I think it would be more sensible to focus on educating and supporting families to understand the certificate system, empowering and training parents to set boundaries, and getting retailers and publishers to show responsibility in marketing and selling violent games (I’ve written about this previously).

That way, I may never again have to tell an outraged 8 year old that he’s not allowed to pay Grand Theft Auto, while his mother looks on impotently. 

Doctors: strike by all means, but understand the game being played

Let me make a few things clear. I bow to no-one in my commitment to the NHS. Competitive NHS-devotion is a tiresome sport, but I’ll play it if necessary.

I think that Jeremy Hunt is out of his depth as health secretary, and has handled the junior contract poorly. More broadly, I abhor the fragmentation and privatisation visited upon us by the health and social care act. Still more broadly, I reject  the discredited economics of austerity, and the mantra that adequately funding the NHS is unaffordable.

I also think the current tabled offer from the DH is crap for junior doctors, and for the profession as a whole. It’s quite right to say that this is part of a process of demoralisation that is aimed at reducing doctors to functionaries within a factory-like health service. The new contract, introduced as it stands, is bad for doctors.

But…. Is it bad for the NHS as a whole? There are reasons to think it might be, but think about it from the DH perspective: you can’t spend any more money, but you’re committed, partly by manifesto and partly by belief that more doctors around at the weekend might make things safer, to make out of hours cover cheaper.

I’m not saying the DH has got it right, it hasn’t, but we need to understand the aims and constraints under which they have to operate. An argument is put forward by DH et al that the new contract would be better for the NHS as a whole, and though we may disagree, we cannot assume we are right. The truth is, we can’t  know for sure what effect the new contract would have on patients.

So, enter the BMA. As the doctors’ trade union, the BMA are quite within their rights to fight this proposed contact on behalf of their members. They seem awfully certain that the new contract is a clear and present danger to patients, but presumably they have a vault of evidence for this stored under BMA house. Let’s leave that aside for now.

They also claim, repeatedly, that the government are preventing negotiation in two ways: by threatening contract imposition, and by restricting what is negotiable to 1 out of 22 aspects of the contract. The latter is easily dealt with-it just isn’t true. The government want the DDRB recommendations to be the basis for negotiation. That’s it. The BMA want to go back to the drawing board. Which brings me to contract imposition.

Say the government allow the BMA a veto over any deal, which is essentially the demand being made when people say ‘drop the preconditions’. The BMA know that no possible new contract will be better for doctors than the current one, given the funding situation. Why wouldn’t they stall, and delay, until 2020 when hopefully there will be a new government? You may welcome this prospect but I hope you can see why the DH are less enamoured.

Think that’s a ridiculous timeline? The DDRB made their recommendations in 2012. The BMA walked out of negotiations over a year ago. Four years doesn’t seem like such a long time if you take that perspective.

In any industrial dispute, both sides have a nuclear option. The employers have imposition, the workers have strikes.

There’s always a weird bit in a industrial dispute, when both sides make bold claims to be on the side of the public, and throw allegations of unreasonable behaviour at each other. The union needs a mandate from its members, and public sympathy, to maximise its strength when, inevitably, the talking starts. Apocalyptic claims made under these conditions tend to wilt once the deal is done.

I’m a bit surprised that more doctors haven’t recognised that this is what is happening now. I’m not sure what the BMA game plan is, but I suspect they’d be very happy to sit down in a few weeks opposite the DH, armed with a thumping strike mandate, broadly supportive public opinion, and no actual strike action having happened. So….

In the interests of doctors, they have exaggerated the intransigence of the government, and taken a polarised, unbalanced view on the service impact of the proposed contract. I’m not blaming them for it, it’s their job as a trade union. I just wish that more doctors recognised what is happening for what it is.

This is not a fight for the future of the NHS.

This is a fight for the status and independence of the medical profession. As such, it is worth having, but not, in my view, worth an all-out strike. Especially as negotiation could begin tomorrow if both parties genuinely wanted it to.