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It is well known that all is not as it should be concerning the HSE’s Child and Adolescent Mental Health Service (CAMHS).
There are many reasons for this, principal among them inadequate bed numbers, recruitment and retention difficulties, poor investment and system fragmentation.
Furthermore, according to the HSE National Service Plan 2018, CAMHS has experienced a 26 per cent increase in referrals between 2012 and 2017.
In December this newspaper revealed that the number of self-harm related adolescent referrals to the Children’s University Hospital, Temple Street, doubled from 2011 to 2015.
Earlier this year it was reported that the parents of an 11-year-old child who died by suicide the day before her first CAMHS clinical appointment are suing the HSE to highlight flaws in its systems. They highlighted delays in trying to access a CAMHS appointment for their daughter who had expressed suicidal ideation. The Irish Times reported that, at the girl’s inquest, psychiatrist Dr Antoinette D’Alton said suicidal ideation is increasing in children as young as seven. Prof Ella Arensman, of the National Suicide Research Foundation, told the inquest that Ireland ranks fifth in Europe in cases of suicide in the 10-14 age group.
More children and adolescents in Ireland are in need of mental healthcare than ever before, and the medical community says it is vital that action is taken now to address mental health service deficits.
However, staffing within CAMHS is at just 52 per cent of the level recommended in A Vision for Change. – an extra 460 posts in CAMHS are required to meet the recommendations of the strategy.
Just over 580 WTE clinical staff work in HSE CAMHS teams nationally. There are currently 70 CAMHS teams.
Almost 19,000 CAMHS referrals were received by the mental health services in 2017 and the HSE expects around 18,830 referrals to be made in 2018.
Yet, just 11,286 cases were seen by mental health services last year. The figure is well below the number of referrals the HSE anticipated to be seen last year, which was 14,365.
Waiting lists for access to CAMHS are as long as 18 months in some areas and many patients have complained of being bounced back and forth between different mental healthcare services while awaiting care.
At a recent meeting of the Oireachtas Committee on the Future of Mental Healthcare, the Chairman, Senator Joan Freeman, psychologist and founder of Pieta House, alluded to the fact that many CAMHS teams do not have a consultant psychiatrist and are therefore “obsolete”.
At the time of publication (May 2017), the Sláintecare Report not- ed that in August 2016, 2,080 children and adolescents were waiting to be seen by CAMHS, with 170 waiting for over 12 months.
Yet by September last year, some 2,333 were awaiting a first appointment referral, with 317 waiting more than one year, according to HSE data.
This shows that demands on the service are increasing and that the numbers waiting for urgent care are on the up.
This begs the question, is enough really being done to adequately meet the needs of vulnerable children and adolescents, despite the evident challenges?
“The Committee that I am chairing is made up of members who leave their parties outside the door. They’re all very distressed at what they’re hearing about the services locally. The job we’re doing is not to get at anybody… but to focus on solutions,” Senator Freeman remarked.
Admission of children to adult mental health units Between January and May last year a total of 44 children were admitted to adult psychiatric units, an increase of eight on the figure for the same period in the previous year,
CHO 1 (Cavan, Monaghan, Leitrim, Sligo and Donegal), CHO 4 (Kerry only), CHO 5 (South Tipperary, Carlow, Kilkenny, Wexford and Waterford) and CHO 8 (Louth, Meath, Laois, Offaly, Longford and Westmeath) had no out-of-hours CAMHS service.
This means that in these areas, which cover more than half the country, children with mental health units might need to take place in certain circumstances.
“If it happens, we must ensure important safeguards are in place and to keep the welfare of the child central at all times,” Senator Freeman stated during the debate.
Senator Freeman, speaking to the Medical Independent (MI), noted that if a psychiatrist has done everything to get a bed in a children’s unit for a child and cannot do so and if they are admitted to an adult unit, that her amendment states that the child must be separated from adults, housed in a child-appropriate environment and that their case must be reviewed at least once every 24 hours. They must also be segregated by gender, her amendment advises.
Funding and investment
Like all healthcare services, funding is a key issue for CAMHS. But determining how much funding the service is actually in receipt of is something of an elusive topic.
Recent meetings held by the Oireachtas Committee on the Future of Mental Healthcare have teased out the issue, with some, albeit not total, success.
Some Community Healthcare Organisation (CHO) chiefs were able to provide information on the amount spent on CAMHS in their region, while others were not. Nationally, the total CAMHS spend is unknown.
Senator Freeman said this is simply “unacceptable”. The Committee has since asked each CHO to provide information on their spending on CAMHS, with a deadline of the end of February to provide the information.
“How can we ask for more money for mental health when we don’t know how much is being spent?” Senator Freeman stated.
“We are trying to make the HSE accountable for how it spends its money.”
The Committee has also invited two CAMHS teams that are working well and two CAMHS team that are not operating as effectively as they should be, to appear before it this month.
Ms Anne O’Connor, HSE National Director Community Operations, explained at a recent Committee meeting, “because of the nature of our systems we cannot capture a breakdown of the information on CAMHS”.
Mr Stephen Mulvany, HSE Chief Financial Officer and Deputy Director General, said at the meeting, “we do not yet have a system that allows
us to run a routine report and gather separately all the child and adolescent mental health services, CAMHS, or all-age costs”.
“The HSE is 12 years in existence and still does not have a single integrated financial or human resources system. It certainly does not have a single integrated mental health system or electronic health record (EHR), for mental health.”
The Sláintecare Report, pub- lished last year by the Oireachtas Committee on the Future of Healthcare, recommends that €47 million be invested in CAMHS teams by year five of the plan and the resourcing of a universal child health and wellness service at a further cost of €41 mil- lion over the first five years.
The report also recommends a child and adolescent liaison service at a cost of €4 million, delivered by year-five of the plan.
Ms O’Connor said at a meeting of the Committee in November that the HSE is commencing an initiative for those aged under 18 years to improve access to counselling in primary care at a cost of €5 million.
“That relates to the recruitment of 120 assistant psychologists and a number of qualified psychologists. They will work with those under 18 years of age and keep them away from the mental health services, if I am honest, by providing that first-line of defence and early intervention. This is something for which there is huge demand. I am not sure how we will get to the stage of meeting all the demand. We are starting with the under 18 year olds because we believe that is a huge gap and that we have young people bouncing into CAMHS as a result of that lack,” Ms O’Connor explained.
Ms Kathleen Lynch, former Minister of State for Primary Care, Mental Health and Disability from 2011 to 2016, took issue with Ms O’Connor’s remarks, however, describing them as “fascinating”. According to Ms Lynch, she put in place this very initiative in the dying months of the previous Government in 2016. She also expressed great concern that the initiative was only now being rolled out some two years later.
She called for the establishment of a more “integrated CAMHS service”, noting that “an overarching piece between adult and child mental health services” is required.
Furthermore, Ms Lynch agreed with the widely held view that “everything gets sent to CAMHS and it can’t deal with it. CAMHS is an urgent, acute intervention service, but unless we get the psychologist posts in place in primary care every referral will continue to go to CAMHS”, she argued.
An investigation of CAMHS car- ried out while she was in Government confirmed that two-thirds of people on the CAMHS waiting list should not have been on the waiting list, but with other services, Ms Lynch added.
In a recent presentation to the Committee on the Future of Mental Health, the IMO called for improved mental health services for children. At the meeting, the IMO demanded that sufficient resources be allocated to general practice with direct access, on GP referral, to publicly funded counselling, psychotherapy and occupational therapy services and supports in the community. “Our GPs describe the situation in our CAMHS as ‘heart-sink’,” Dublin GP Dr Ray Walley told the Committee. “Young patients with serious mental health and behavioural problems face long delays for assessment with urgent access only available through emergency out-of-hours services or emergency departments. With insufficient resources allocated to general practice and limited access to supports and psychotherapy services in community or primary care, referrals to CAMHS services are increasing. At the same time pressures on CAMHS services have raised the threshold for acceptance and patients are increasingly referred back to the GP without assessment and where options for treatment in the community are limited.”
Dr John Hillery, President of the College of Psychiatrists of Ireland, agreed that the service was under stress and that there are not enough child psychiatrists, allied health professionals, psychologists and other therapists in place.
He called for more early interventions to be put in place for children at a young age to help avoid them having to seek mental healthcare.
“People often end up on the waiting list for CAMHS because they haven’t had an assessment for things like cognitive disability, learning difficulties or autism, which don’t necessarily need to be done at a CAMHS level. If the assessments are done and the support needs are delineated then they can be put in and this saves the need to go to a psychiatrist or a specialist mental health team later. Those issues are still relevant today,” Dr Hillery advised.
Nationally, there are four CAMHS units located in Cork, Galway and two in Dublin.
In addition, there are two private units in Dublin, one at St John of God’s Hospital and another at St Patrick’s Hospital.
At the time of this article, there were 70 of the 76 available operational beds open nationally within HSE units, according to a HSE spokesperson.
The six closed beds were made up of two beds at St Joseph’s Unit and Fairview Hospital, Dublin and four beds at Eist Linn, Cork.
It is accepted that these figures represent a shortage of operational beds in child units and plans are in place to increase bed numbers.
General Secretary of the Psychiatric Nurses Association (PNA), Mr Peter Hughes, during a recent address to the Oireachtas Future of Mental Healthcare Committee, noted the issue of bed closures within CAMHS.
“In May 2017, 50 per cent of the admission beds in Linn Dara, Child and Adolescent Mental Health Services (CAMHS) in Dublin were closed until the end of October, ie, 11 of the 22 beds were closed. This was directly due to nursing shortages, as the service was short 50 per cent of the complement of nurses.
“A Vision for Change recommended 100 CAMHS beds nationally. Following the closure of the beds in Linn Dara, the bed numbers were reduced to 52 nationally.”
Dr Hillery posited that many trained health professionals do not opt to work in CAMHS teams, because the teams are not fully staffed.
“As regards recruitment, we are training people and people are looking to work in these teams but the teams aren’t available so they go and work where they can work in teams they are trained to work in. Then you don’t attract people because you don’t have the teams. We also need to have sufficient people employed to allow things like sick leave, parental leave and maternity leave without services being decimated. We need to put in place a system where people can take those leaves without feeling that the service is going to suffer,” Dr Hillery advised.
A 10-bed child and adolescent mental health unit is planned for the new National Forensic Mental Health Hospital in Dublin, due for completion in 2020.
Mr Hughes noted that construction of the new National Children’s Hospital would create 20 beds for child and adolescent mental health, eight of which would be dedicated to a service for eating disorders.
“However, considering the difficulties in recruiting and retaining nursing staff in CAMHS services, this development will of itself create some challenges,” Mr Hughes warned.
A public consultant paediatric psychiatrist, who spoke on the condition of anonymity, raises several serious questions about the operation of the CAMHS.
The psychiatrist cited recruitment within the service as difficult, claiming that many staff are on temporary contracts or are too junior or unqualified for the responsibilities placed on them.
In June 2015 the HSE introduced the CAMHS Standard Operating Procedure (SOP). This is cur- rently under review by the HSE, which recently sought submissions to inform the review.
The psychiatrist claims, however, that most consultants have already refused to sign up to the procedure.
“The HSE is unable to fulfil SOPs and broke its own policies and procedures developing same. SOPs inappropriately attempt to standardise clinical issues that are frequently not standardisa- ble, not just because of how men- tal illness has such variable presentation but because the wide age range of young people means their needs are very different as is their environment, therefore a flexible response is required,” the psychiatrist stated.
The most important issue is that there is currently no acceptable CAMHS-specific governance structure that allows risk to be managed and operational issues to be addressed, they maintained.
The psychiatrist also alleged that operational and clinical tasks are being blurred and this “reduces clinical capacity and lengthens waiting lists”.
When asked about the HSE’s position on the view that there is no acceptable CAMHS govern- ance structure that allows risk to be managed and operational issues to be addressed, a HSE spokesperson outlined that all mental health services, including CAMHS, are managed by the head of mental health services within each of the nine CHOs.
“Clinical governance is provided to CAMHS consultants by the executive clinical director while other members of the CAMHS team are line managed by their respective discipline heads. The head of service has overall operational governance of all services that provide mental health in each CHO. Each head of the mental health service has devolved re- sponsibility from the chief operating officer of each CHO area and is responsible for ensuring that there are governance and reporting structures in place that manage operational issues including risk management,” said the spokesperson.
National bed manager
Another major criticism of the CAMHS is that there is no dedicated bed manager to help clinicians in locating beds for patients.
According to the psychiatrist who spoke to MI, the HSE frequently expects consultants to ring every unit repeatedly on a daily basis to locate beds for patients, when it should have a bed manager to do this.
A HSE spokesperson confirmed that no bed manager for CAMHS exists, but noted that bed returns for each unit are collected centrally to identify where beds are.
“Any vacant beds are filled based on the clinical priority of those young people on the waiting list. The decision to offer a bed is the clinical responsibility of the inpatient CAMHS consultant, based on their clinical assessment in consultation with the other members of the clinical team,” said the spokesperson.
According to the HSE, some 12 child and adolescent patients travelled abroad for mental health treatment in 2017 to avail of care under the Treatment Abroad Scheme (TAS). Others have availed of care by travelling abroad via the EU Cross Border Healthcare Directive.
To qualify for treatment under the TAS, the treatment concerned must not be available in Ireland or must not be available within a reasonable time, taking account of a patient’s current state of health and the probable course of the illness. Patients must also be referred through the public health system.
“In 2017, 28 TAS applications were approved for such patients to avail of mental healthcare treatment outside the State under the HSE TAS. Some 12 patients travelled to avail of such treatment abroad in 2017,” a spokesperson stated.
“In keeping with the HSE’s requirement to uphold patient confidentiality, information is releasable only where five or more cases are identified. We are unable to provide you with information pertaining to the CBD [EU Cross Border Healthcare Directive] on this basis.”
Another major issue of concern is the lack of specific child and adolescent psychiatry training held by clinical staff working within CAMHS.
A HSE report published in 2015 titled An Education and Training Review of Nurses Working in Child and Adolescent Mental Health Services in the Republic of Ireland, highlights this very problem.
It states, “a high percentage of staff nurses (60 per cent) did not have specific training for their current role”.
This report presented the findings of an education and training review of nurses working in CAMHS services nationally.
Among many recommendations, it advised, “national clinical guidelines are required to inform clinical practice and the development of education and training programmes for nurses working in CAMHS”.
The same issue exists with regard to some adult psychiatrists with no child and adolescent training being hired by the HSE to work within CAMHS.
The psychiatrist, again speaking on the condition of anonymity, highlighted that child psychiatry is a very different specialty to adult psychiatry and that in some cases there are “adult psychiatrists who have no specific child psychiatry recognition with the Medical Council working with young people”.
“The HSE has knowingly employed psychiatrists without appropriate expertise or qualifications in child psychiatry in [parts of the country]… are parents aware their children are not in fact seen by a specialist?,” the psychiatrist queried.
It is understood that in certain cases adult psychiatrists have been hired due to HSE difficulties in recruiting child and adolescent psychiatrists.
MI asked the HSE how many CAMHS staff have specific training in child and adolescent psy-
chiatry. A spokesperson said: “We do not collect this information nationally.” MI also asked how many adult psychiatrists are employed in CAMHS, and was told: “We do not have access to this information.”
Dr Hillery said that patients are entitled to be seen by a specialist and should only be seen by a non-specialist if supervised by a specialist.
“People are entitled to specialist care and specialists need to be appropriately trained,” Dr Hillery stated.
HSE plans for 2018
Among the HSE initiatives planned for CAMHS in 2018 is the delivery of a “major improvement initiative to increase the numbers of CAMHS referrals to be seen in 2018 by 27 per cent, compared to 2017, ie, over 3,000 additional service users year on year”.
But the HSE, in its HSE National Service Plan 2018, states that this will be dependent on agree- ment with existing multidisciplinary teams to the delivery of incentivised work taking place outside core hours, as well as the continued delivery of the current activity in parallel with this targeted improvement.
The initiative will be funded, once off, through A Programme for a Partnership Government 2018 funding.
The funding is to provide a seven-day per week service for CAMHS to ensure supports for vul- nerable young persons in line with Connecting for Life – Ireland’s national strategy to reduce suicide.
It will also help to progress day hospital services within CAMHS, develop eating disorder specialist community teams and implement the recently developed CAMHS advocacy model.
Commenting on the advocacy model at a Committee meeting late last year, Ms O’Connor said that the pilot, in CHO 2 (Galway, Roscommon and Mayo), has gone to tender.
“The CAMHS advocacy project has been extremely complex in that advocacy for children is very different to having advocacy in place for adults, for all sorts of reasons. We have gone to tender for an external agency to run that. That tender is out and we hope to commence that initiative at the end of this year, although I am not sure of the date as we have to do the pilot piece first to see how it works.”
Recruitment and retention
HSE officials often complain about the international healthcare recruitment problem and how it affects services.
CHO 1 has even gone to the lengths of developing a bespoke recruitment campaign to attract staff to mental health services here. It is understood HSE representatives attended a con- ference on CAMHS in Geneva in July 2017 to recruit CAMHS consultant posts. Skype interviews arranged from the initiative were planned to take place last month (February).
The recruitment drive was instigated due to an ongoing problem in recruiting consultant psychiatrists in the region.
CHO 4 (Cork and Kerry) recently established a taskforce comprising HR and medical personnel to focus on recruitment into CAMHS, due to ongoing difficulties.
Mr Ger Reaney, Chief Officer for CHO 4, said at a recent appearance before the Oireachtas Committee on the Future of Mental Healthcare that, “we face a number of challenges in addition to the recruitment challenge. We experience waiting times for child and adolescent mental health services due primarily to recruitment issues and the absence of certain staffing levels”.
Ms O’Connor also stated in an address before the Committee last November that, “staff recruitment in mental health continues to be a significant challenge resulting in the underdevelopment of mental health teams in certain areas which then impacts on access, targets and waiting times”.
Yet, Prof Joyce O’Connor, former chairperson of the Expert Group on Mental Health Policy and Dr Fiona Keogh, Senior Research Fellow at NUI, Galway, in their appearance before the com- mittee last December took a somewhat different view.
They seemed to point to the issue of effective leadership and not recruitment alone, as having the most impact on reducing waiting lists.
“CAMHS waiting lists are a ‘symptom’ of a system that is fragmented with referrals for any support often inappropriately going to CAMHS,” they outlined in a submission.
“Five of the nine CHO areas do not have waiting lists over 12 months for CAMHS. Factors associated with lower waiting lists: Effective leadership, effective coordination and team working, close to full staffing of teams (including key staff members), no recruitment problems.”
It is evident that improvements in community healthcare, which deals with over 90 per cent of mental health cases, could lead to a domino effect in reducing CAMHS waiting lists and de- mands on the service.
Planned improvements in psychology supports and services for young children, along with ear- ly interventions in schools to meet the needs of children with specialist needs, could lead to a more effective, targeted service, say the relevant experts.
But in order to achieve this, they say it is imperative that the State and the HSE provide the necessary funding, training, staffing and support.