Suicide is one of the leading causes of death in young people in the UK. Statistics show that there were 922 suicides and probable suicides by people aged under 25 from January 2014 to December 2015. One in ten children are affected by mental health problems with around 460,000 referrals to children and young people's mental health services made per year. At any one time, 1,300 young people are receiving inpatient treatment for mental health problems.
Evidence suggests that the demand for mental health services for children and young people is increasing, but it is unclear whether the capacity of services is also changing, to match this demand.
In October 2017, the CQC published its initial review of children and young people's mental health services. The report was commissioned to review the quality and access across the system of mental health services for children and young people and to inform what would help to improve these services.
The report highlights that the differences in local commissioning priorities and practices means that the availability of services varies between different areas of the country (the so-called postcode lottery). There is variation in the level of funding for these services in different regions of the country, and different levels of referrals to these services. This variation in children's mental health spend was widely reported in the media in 2017, with calls for children's mental health funding to be ring-fenced, to ensure that allocated funds actually reach the front line, rather than being spent elsewhere.
Areas identified as needing improvement
The CQC report outlines several areas which services need to improve:
This is listed as the area of greatest overall concern for specialist CAMHS services. Safe care is defined as "care that protects children and young people from abuse and avoidable harm". Services should continually manage risks to children and young people, and involve patients in managing their own risks. There should be a culture of positive risk-taking to minimise restrictive practices, and a supportive culture of openness, transparency and learning when things go wrong. The physical environment should be safe, with equipment checked regularly, and inpatient services should be clean, to protect against infection.
2. Access to timely care and support
There are huge concerns regarding the waiting times for children to access CAMHS services, which can be up to 100 weeks from referral. Average waiting times vary depending on locality, and a child without "urgent" mental health needs may have to wait a prolonged period of time before they are able to access services.
Crisis care was found to be limited, and out of hours crisis support was generally provided by specialist adult psychiatrists, rather than psychiatrists specialising in children's mental health.
CQC inspectors found that children could not always be placed in the inpatient setting best suited to their needs, and that the demand for beds greatly outweighs the availability of beds in certain parts of the country. Some children are therefore having to be admitted to adult wards. Some services are also unable to offer a psychiatric intensive care unit (PICU) in their locality, and so children are being admitted to PICUs some distance from their home.
Some CAMHS services only offered low levels of staff with inadequate training, with a lack of appropriate support of regular supervision for staff.
4. Person-centred care
Some services are failing to provide person-centred care that meets the specific needs of children and young people. These services are not adequately assessing the physical health needs of patients, and there were issues with poorly maintained or inappropriate inpatient facilities. For instance, some services failed to provider facilities to provide dignity and privacy when children used the bathroom.
The report highlights that some CAMHS services were using out of date or poorly implemented policies on important aspects of care. More has to be done to ensure staff compliance with the Mental Health Act 1983, and that correct safeguarding policies are being followed.
6. Recording and reporting information
Gaps were found in the recording and reporting of important information necessary to ensure safe, effective, and compassionate delivery of care. Care plans and other records relating to incidents, restraint, consent, risks and mental capacity were sometimes found to be inaccurate or complete.
The fundamental supply/demand problem
The CQC report acknowledges that there are several barriers to providing high quality care, in particular due to the supply and demand issue in children and young people's mental health. Childline reports that one in three counselling sessions it provides is mental health related, and that counselling for suicidal feelings has reached its highest levels.
There is a huge reported increase in the demand for out of hours and emergency mental health care for children and young people, and referrals to specialist mental health services are growing five times faster than the size of the teams providing the services. The report refers to "a system under pressure, leading to long waiting times, appointments being cancelled, and some children being unable to access timely and appropriate help".
One of suggestions from the CQC in terms of good practice is that access to services is improved. The report gives the example of a CAMHS service installing a team in the emergency department of the local acute hospital, operating seven days a week, 8am to 11pm to ensure there is not a long wait for specialist mental health support. Another example is a telephone service to support children, young people, their families and carers during a mental health crisis. Several services use "crisis cards" or "crisis plans" to ensure children know how and when to obtain support if their mental health deteriorates. A plan could include the telephone numbers of trusted adults, the Childline telephone number, and a clear plan about what they should do in a mental health emergency.
What is the Government proposing to do to assist?
The Green Paper on Transforming Children and Young People's Mental Health Provision (December 2017), reports that NHS England currently has a major drive towards improving inpatient care, by opening between 150 and 180 new beds, and "ensuring that these are the right beds, and in the right place in the country". It is the Government's ambition that by 2020/21 no children should be inappropriately admitted or sent out of area to receive anything but the most specialist mental health care.
The Government is aiming to improve crisis care, with eight areas testing different crisis approaches through "Emergency and Urgent Care Vanguards". The New Care Models in Tertiary Mental Health Programmes also supports more appropriate local provision by jointly commissioning between NHS England and Providers so that children in need of inpatient beds access one close to home. The savings from reducing and minimising inpatient stays are to be reinvested in community services for children presenting in crisis.
Another proposal is to reduce waiting times for specialist children's mental health services. New Mental Health Support Teams will be funded to provide specific extra capacity for early intervention and ongoing help. They will provide interventions to support those with mild to moderate needs and supporting the promotion of good mental health and wellbeing. The aim is for children and young people to be able to access NHS-funded services within four weeks.
These proposals are to be rolled out from 2018 to 2022/23. However, it remains to be seen whether it will assist in the fundamental supply and demand problem currently experienced by children and young people's mental health services. Indeed, the Shadow Health Secretary Jonathan Ashworth has raised concerns that the four week target may only be met by raising the threshold for accessing CAMHS services. It is possible therefore that "solving" one problem may only serve to create another.
For further information or to discuss any aspect of this article, please contact Sumayyah Malna, Solicitor.