Thursday, 27 November 2014

Mental health services for young people criticised

Mental health services are often inadequate for adults, being described as a "Cinderella service", meaning it's often ignored by a cruel stepmother (aka. the government).

So what about younger people with mental illnesses?

The National Assembly's Children & Young People Committee recently published its report (pdf) on their long-running inquiry into Child & Adolescent Mental Health Services (CAMHS), covering how these services are funded and resourced, regional variations, respect for children's rights and access to treatment.

In an unusual move, the Committee didn't make any recommendations as the Health Minister, Mark Drakeford (Lab, Cardiff West), is carrying out a "root and branch review" (pdf) of CAMHS. Therefore the Committee believed it would be inappropriate to make recommendations until that review has finished, instead making observations.

The evidence was shocking.

The Welsh Government's Role

The Welsh Government have no fewer than seven policies and strategies on CAMHS, but a 2009 review said CAMHS were "putting children at risk". Since then, mental health policies have changed from child-specific to all-age, which the Royal College of Nursing (RCN) said has "created an impetus for improvement" but CAMHS was now "seen as the Cinderella of the Cinderella service".

The out-going Childrens Commissioner, Keith Towler, said he was concerned about the removal of specific mental health strategies for children and young people, and this might "dilute regard to the intentions of the UN Convention of the Rights of the Child (UNCRC)".

Previous reports have also slammed CAMHS as not offering standardised delivery, not undertaking proper risk assessments and poor caseload management.

The Health Minister said Local Health Boards (LHBs) have "made progress" on improving these services. In his own evidence, he said he was in contact with LHBs four times a year, and they often give him feedback on what improvements are being made. Other witnesses say that CAMHS has had a much keener focus on it over the past 12-18 months than it had previously.

The Committee were concerned that none of these reviews have led to any significant changes, that Welsh Government targets weren't clear enough, and also – understandably – had worries about the possible negative impact a removal of child-specific mental health policies would have.

Access to CAMHS

Demand for CAMHS has doubled in four years, and in some parts of Wales even more so.
(Pic : BBC)
Everything points to an increase in the cases of diagnosable mental illnesses amongst young people – leading to an under capacity in CAMHS - but the picture across Wales is unclear as there's little to no data collection. Also, there was regional variation in access to certain specialist services, in particular young offenders.

Demand for CAMHS has doubled (+100%) since 2010, from 1,204 referrals to 2,410 referrals, with the sharpest increases in the Aneurin Bevan LHB (Gwent), which increased by 241%.

So difficulties in accessing CAMHS were a running theme throughout the evidence received by the Committee, with many parents and patients saying they had a negative experience trying to get the help they need, which put serious strain on families.

Some parents say specialist referrals have been rejected "without explanation", and some GPs said rejections occurred without even seeing the patient. LHBs only started to collect data on refused referrals from November 2013, and the figures show that since then there've been 2,835 refusals, but because this didn't include Betsi Cadwaladr LHB (North Wales), it's said to be an underestimate.

Access to specialist CAMHS often requires a diagnosable mental illness, but many witnesses believe this ignores the needs of children who endure traumas and psychological abuse which aren't officially illnesses but can permanently affect mental health. This often means CAMHS is, as one witness described, being treated as an "accident and emergency service" where treatment is only offered for urgent cases.

Early intervention programmes are said to be "limited", despite the Mental Health Measure 2010, which placed a duty on local authorities and primary care to assess mental health needs. There were concerns though that too much of the money resulting from this legislation (around £3.5million) has gone towards adults instead of children and young people.

School counsellors were said to be important, but this often meant children with serious mental health problems were being referred to them, with their limited training, instead of specialist psychologists.

The Health Minister doesn't believe that the number of young people with mental illnesses has doubled, and says CAMHS needs to be put in the context of a specialist health service which deals with the most serious cases, not a general mental health service. He did, however, recognise the long waiting times, though he insisted that, "more children are being seen within the target times than at any other time".


Staff shortages and high staff turnover are factors said to put
strain  on families of young mental health patients.
(Pic :
The irony in all this is that mental health services (in general) are said to be the largest single area of expenditure in the Welsh NHS, with £617.5million spent in 2012-13.

It's fairly obvious where this money is going though. £82.75 per head is spent on adult mental health, £58.18 on the elderly and just £13.94 for CAMHS.

Unsurprisingly, this low level of funding raised concerns, though LHBs wanted more clarification on how much they should spend on CAMHS as specific services aren't ring-fenced. These financial problems even filter through into local authorities, where Rhondda Cynon Taf Council complained about cuts to social work budgets "eroding" the social work side of CAMHS.

Shortage of staff and high staff turnover was highlighted by parents, as this puts more pressure on them and carers, meaning patients often can't build a relationship with staff.

It's said there are 9.9 full-time equivalent CAMHS staff per 100,000 population, compared to 15.9 for adult mental health. The recommendation of the Royal College of Psychiatrists (RCP) is between 19.3 and 23.4 staff – excluding young offending and substance misuse work.

The Health Minister said mental health problems facing adults and the elderly are "more enduring" and often need closer attention and (sometimes) higher security, while he described the RCP's guideline staffing levels as "aspirational".

Delivery & Structure of Services

Despite investment in the likes of Bridgend's Ty Llidiard, in-patient CAMHS services are still
seen as inadequate, and the clinic-based nature of CAMHS was criticised by patients.
(Pic : NHS Wales)
The Committee say the evidence they received points towards there needing to be a more consistent service across Wales, especially to bridge the gap between rural and urban areas.

Current CAMHS are said to be limited by 9-5 services offered by clinics, which is said doesn't suit the needs of the most vulnerable and complex cases who need round the clock or out of hours services. Basing services in clinics also reduces access in rural areas where there's strict timekeeping for appointments and longer distances to travel.

Patients themselves said clinic-based services weren't meeting their needs, but they praised some of the voluntary sector programmes and courses. Unfortunately, these projects are dependent on sketchy sources of funding and often close with short notice.

Due to the clinic-based provision, urgent CAMHS cases are often sent to hospital accident and emergency departments as "a default setting" – usually, it's said, as a result of self-harm or substance abuse. This often meant children were admitted onto adult mental health wards, or children being discharged too early without proper follow-up support. Some patients even said that attempting suicide didn't meet the threshold to qualify for CAMHS services.

As a result of in-patient bed shortages, many CAMHS patients are being sent out of area, which is a pretty expensive option, with the practice criticised by the Auditor General in 2013. This led some patients to believe they were being "institutionalised" or "kept away". Despite investment in new in-patient facilities – like Ty Llidiard in Bridgend – these often fail to meet demand.

There were extreme concerns about transfer from CAMHS to adult mental health services, with some patients effectively "dropping out" of the system instead of making a smooth transition. Patients and their families effectively have to start from scratch.

In terms of treatments, access to psychological therapy is said to be increasingly limited, while some clinical psychologists criticised the widespread use of medication (without being used alongside other therapies/strategies) as an "easy option". One even said that in 20 years time we could be looking back on it as a scandal.

The Health Minister and his officials said operating hours of community mental health teams are being extended to be increasingly available at weekends and nights, and the Minister said community-based treatment will reduce admission rates and allow services to be delivered flexibly. They also said an extra £650,000 was found to enable current mental health staff to deliver psychological therapies.

A(nother) hidden national disgrace?

While many people – including myself, it has to be said – are preoccupied by things like the ambulance service and hospital reorganisation, this has gone under the radar as a hidden national disgrace.

I suppose in many ways, this post – easily the most important of the three blogs this week, but will probably get a fraction of the interest – feeds into the other two.

Firstly, I'm surprised the reaction to this report hasn't been stronger because it really puts the outcry over AMs pay into some much needed perspective. Secondly, the poor services offered some of our most vulnerable young people – especially when compared to the elderly - underlines an argument in favour of them being able to vote, as this is yet another policy area where they're perhaps getting shafted.

If there's a single thing out of all the evidence that worried me most of all it's children being admitted onto adult wards. That must be terrifying for them, especially if they have a history of abuse and/or if the adults need constant care or heightened security.

I'm sure it's very different in reality, but the way the Health Minister has been quoted in the report makes him sound flippant in the face of such glaring failures. So in many ways I'm disappointed the Committee chose not to make any concrete recommendations because their input, based on the evidence they've received, might've helped in the review process.

I can't really add anymore. The evidence is enough to make you depressed by itself.


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