Crisis in child mental health services has been decades in the making

Reviews and regulation of Child and Adolescent Mental Health Services are critically important but cannot have the desired effect if we do not have the doctors available to staff these crucial services, and the appropriate ICT, clinical and managerial structures in place nationwide, writes Professor Fiona McNicholas
Crisis in child mental health services has been decades in the making

Our children and adolescents deserve so much more from our health system. File photo

The interim report by the Mental Health Commission into Child and Adolescent Mental Health Services (Camhs) in Ireland published this week has led to public and political outrage and, while shocking, is not at all surprising. It makes for very distressing reading and is a huge indictment on our health system.

The College of Psychiatrists of Ireland welcomes this report, which regrettably echoes many concerns we have previously identified. However, we are highly concerned that the report does not adequately take account of of other problems that are having a major effect.

For example, the report states that the lack of governance in many areas is contributing to “some inefficient and unsafe” Camhs practices. The College argues that this lack of governance is, in fact, a major systemic issue which is having a fundamentally negative effect on all Camhs services around the country.

The report outlines two key recommendations to mitigate against further risk; namely “an immediate clinical review of all open cases in all Camhs teams, with particular focus given to identifying and assessing open cases of children who have been lost to follow-up and physical health monitoring of those on medication” and the “immediate regulation of Camhs, under the Mental Health Act 2001”.

Doctor shortages

However, the absence of recommendations addressing the poor governance structures and the significant lack of doctors in psychiatry is a serious omission.

In recent days, patients and families have spoken of the difficulties they have faced in accessing Camhs, and the variations in care received once a referral is made or treatment offered. Some patients have waited months in hospitals for admission to specialist in-patient child psychiatry units, and in some cases, police protection has even been necessary in the absence of any emergency mental health service access.

How has this awful situation developed? Decades of poor resourcing, insufficient funding, a lack of basic ICT that includes electronic data management and patient record systems, and no meaningful implementation of official plans to either recruit or retain doctors in psychiatry have led to the situation we are facing today.

As the interim report outlines, full, multi-disciplinary team staffing does not exist consistently in the community, nationwide, with many reporting that staffing is below 50% recommended levels.

The College of Psychiatrists has consistently argued that we are facing a major crisis in doctor recruitment and retention. At present we need a minimum of 200 child and adolescent consultant psychiatrists in Ireland across all specialist mental health services for children, which includes 125 for Camhs, but currently, we have less than two-thirds of that number practising today.

Those doctors that do practise in Camhs simply do not have the adequate infrastructure to perform their roles competently and effectively. They are overworked, underappreciated, and working under unsustainable pressure in a system that does not appear to value the hugely important work they do.

Research conducted by the College along with other stakeholders in 2020 suggests high levels of burnout in over 75% of consultants and Camhs team members, with the majority having seriously considered changing jobs. The majority have also expressed a lack of confidence in the HSE management of their service, as well as the government’s commitment to funding. Ultimately, patients will be negatively impacted because of this.

Other issues

How can we address these problems? Reviews and regulation are critically important but cannot have the desired effect if we do not have the doctors available to staff these crucial services, and the appropriate ICT, clinical and managerial structures in place nationwide.

At a minimum, we need to see integrated governance structures, involving consultant child and adolescent psychiatrists at national level, within the local management and community care organisations planning and operating the services, and at the frontline leading and directing the multi-disciplinary team.

Despite the College calling for an inspection of community mental health services, including Camhs, this has not occurred. Had these happened before now, then the serious problems identified in the Maskey report into South Kerry Camhs would have been uncovered far earlier, saving many families untold suffering and pain.

As we have called for previously, a Mental Health Service Director and a Mental Health Lead for Children are now more than ever urgently required. The Mental Health Lead for Children should be a highly trained child and adolescent psychiatrist, with expertise in effective service delivery internationally, a track record in management, and with sufficient clinical experience to understand the complexity of child psychiatry and patient needs.

The service provided by Camhs is equivalent to hospital-level, consultant-led, multi-disciplinary team care, but provided in the community for children and adolescents with moderate to severe mental illnesses. Consultants and teams in both settings need the same support structures, yet that is sorely lacking at present.

Unfortunately, these serious problems do not start or end with Camhs. We are failing children who need care at all levels. Along with Camhs shortcomings, there has also been completely inadequate development of primary care services, disability services and other services or interventions for children, and as a result Camhs has been inundated as patients have nowhere else to go.

We now need to see urgent emergency-level planning, supports and resourcing with clear immediate actions and accountability to rectify the serious deficits in Camhs and the wider mental health services. Our children and adolescents deserve so much more from our health system.

  • Professor Fiona McNicholas is a Child and Adolescent Consultant Psychiatrist and a member of the College of Psychiatrists of Ireland. The College is the professional and training body for psychiatrists in Ireland and represents 1,000 professional psychiatrists (both specialists and trainees) across the country

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