Colman Noctor: Primary mental health care system could be a game changer for Irish children

Camhs is attempting to serve a function it is not equipped to or able to fulfil

The degree to which these services are under-resourced and understaffed in Ireland is jaw-dropping.

The Child and Adolescent Mental Health Services (Camhs) is in the headlines again for all the wrong reasons.

Further to the 2022 Maskey Report, detailing the scandals in the South Kerry Camhs, another report was published by the Mental Health Commission (MHC) last week, revealing what many people already knew — that the service is ‘not fit for purpose’.

MHC chief inspector Dr Susan Finnerty stated it was not possible to guarantee that a child who has mental health needs could have those needs met by the current services, warning the MHC “cannot currently reassure all parents in Ireland that their children have access to a safe, effective, and evidence-based mental health service”.

This is a shocking indictment and one we need to address urgently.

Camhs staff have been crying out for help for years only to have their voices ignored or overlooked, and many will welcome this report, seeing it as an opportunity for change.

However, the problems in providing psychological services for children in Ireland go beyond the remit of Camhs. The degree to which these services are under-resourced and understaffed in Ireland is jaw-dropping.

Over the course of my career, I have worked in all areas of child and adolescent mental health services in Ireland and Britain in various settings, such as in-patient units, community out-patient services, day hospitals, and child psychiatry liaison. I have not worked in the NHS system since the early 2000s, but even then, it functioned far better than the Irish model today.

While this was partly due to allocating a higher percentage of government, it was mainly down to the infrastructure of children’s services, which provided comprehensive early support services. This model allowed Camhs to function as intended and not become a ‘catch-all’ service for distressed children.

For the past 20 years, the British system has employed school-based mental health teams, dedicated ASD services, educational psychology services, and nurse-led ADHD clinics.

The availability of these services has meant Camhs is utilised only by children who require specific psychiatric interventions, and there are other social and therapeutic services available for those who would benefit more from them.

The systemic issues of providing non-physical care to Irish children and families are far more extensive than the remit of Camhs, and adding tokenistic resources like an extra nursing post here or psychiatrist post there, and not addressing the infrastructural shortcomings, is like pouring water into a leaking bucket.

The service has become a convenient ‘whipping boy’ when addressing the shortcomings of the non-physical healthcare of children in Ireland. I deliberately refer to children’s ‘non-physical healthcare ’ needs because the term ‘mental health’ has become so broad and vague that it is almost meaningless.

The central issue is that Camhs is attempting to serve a function it is not equipped nor able to fulfil. The reality is not all children who experience psychological or emotional distress need to attend Camhs.

Re-make the model

Every health system needs different layers of specialism to function. Consider our current model of general medical care and compare it with our mental health services. The two models could not be more different in terms of structure and service. The first level of any health system must be primary care, which is embedded in the community and provides services such as health checks, screening, and early intervention.

These services go a long way to identifying those at risk, allowing care providers to take swift action to minimise the risk of escalation. When more needs to be done, the patient is referred to a specialist who may decide a period in hospital is necessary. But when mental health services are called, the journey usually involves a trip to the GP and an immediate referral to Camhs.

Camhs comprises specialist teams to treat young people with moderate to severe mental illness. But not all emotional distress, trauma, or behavioural issues are mental illnesses. These emotional and behavioural issues certainly are distressing and warrant prompt and extensive intervention, but this is not the remit of a Camhs service.

This misunderstanding is part of the reason we have serious issues with Camhs. It is expected to offer a far more comprehensive service than it is designed to provide. The absence of a primary care mental health service has resulted in Camhs attempting to meet the needs of all young people who experience emotional, cognitive, or behavioural distress, and it is being overwhelmed.

This is not new. As far back as 2003, when I returned to Ireland from Britain, I was part of discussions with senior HSE officials about this issue.

Implementing a primary mental health care system could be a game changer for Irish children needing psychological support. This would involve mental health support systems being made available to every primary and secondary school, and creating a series of non-medical primary care staff who could offer early intervention, for example, psychology, occupational therapy, speech and language therapy, etc. This system would result in only children who require mental health interventions being referred to Camhs.

Providing early access to supportive therapeutic services in the community would allow Camhs teams to do what they were designed to do, and resolve the current crisis in the system.

This new model is little consolation to the parents and young people in distress who cannot access the mental health support they require. It is no benefit to those languishing on Camhs waiting lists for years only to discover they were in the wrong queue. And it is no consolation to the families of young people whose lives have been irreversibly affected by the absence of these services.

Healthcare politics

Access to a primary mental health care system should be considered a fundamental human right. We need to acknowledge its importance and prioritise it accordingly.

The development of supportive psychotherapeutic and social services in the community is an obvious solution to the current problems of overwhelmed services and long waiting lists.

Why has it not happened? It could be because developing these services is a long-term initiative, taking time to bear fruit. It’s a case of healthcare policy versus healthcare politics. It is also impossible to measure the number of people who ‘did not attend a service’ because they received adequate early intervention. So there is no kudos for being the political party that created the provision of primary care services.

While developing a primary care mental health service would be costly, the cost of continuous firefighting and plugging gaps makes less economic sense.

We have had a series of ministers for mental health offering us their solutions, which have included ‘mental health hotlines’ or ‘mental health task forces’, offering impressive short-term soundbites but have had no long-term impact. The role of the minister with responsibility for mental health has changed almost yearly, offering no long-term vision, only short-term optics to garner ‘quick wins’.

The government’s Sláintecare initiative aims to put ‘people at the centre of the health system’ by developing primary and community health services, but this remains the great white hope. Our politicians and policymakers must sidestep cross-party politics and drive through the root and branch changes needed to protect vulnerable children promptly and effectively.

Dr Colman Noctor is a child psychotherapist