LONE ZONE

Published: 20/01/2005, Volume II5, No. 5939 Page 26 27 28

Almost totally bereft of specialist care for children and young people, mental health services are failing where they are needed most. Emma Forrest reports

If mental health is the Cinderella of the NHS, child and adolescent mental health is the beggar that Cinderella would throw crumbs to.

'No-one has ever invested in it or made it a priority, ' says Mental Health Foundation chief executive Andrew McCulloch. 'We estimate that only 10-15 per cent of children are getting the services they need.' Yet commentators conclude that all available evidence suggests that helping those in mental distress when they are young stops worse problems in later life.

'We spend far less per capita on children than adults, which is absurd. It is more cost-effective to intervene earlier in the cycle, ' says Mr McCulloch.

The government does seem at least to acknowledge the scale of the problem. Figures outlined in the children's national service framework estimate that around 1.1 million children and young people under the age of 18 would benefit from some kind of specialist service, and that there are 45,000 young people with a severe mental disorder.

Even a casual look at the numbers of children being treated by child and adolescent mental health services (available through the CAMHS mapping service run by Durham University) suggest that only a fraction of those are being seen by specialists. It also shows that the types of services available around the country - and the waiting lists for them - vary massively.

CAMHS work with different classifications from adult services. Children are classed as having disorders, which include depression and anxiety, as well as behavioural problems, rather than mental illness. Although it is rare for a child to have the symptoms of a severe mental illness, and conditions such as schizophrenia are not thought to develop until teenage years, some evidence links conditions such as attention deficit hyperactivity disorder to severe conditions later in life.

And the numbers of those with problems are on the rise. A recent report by the Institute of Psychiatry found that the number of 15-year-olds diagnosed with emotional problems had increased by a staggering 70 per cent since 1974.

Behavioural problems had doubled.

Models of care for young people are based around talking therapies rather than drugs. The trouble is that not enough are getting it.

Mr McCulloch explains that the patchy nature of CAMHS means services can become isolated from each other and from modern best practice.

'Some places still have the flavour of guidance from the 1960s and 1970s. It is not a problem of lack of commitment from the staff, but some places are small, led by a single CAMHS psychiatrist, with a model of care determined by the staff. They are providing a therapeutic service, but have paid no attention to new models of care and just soldiered on, ' he says.

Government estimates suggest that around 40 per cent of children with a mental disorder are not receiving a specialist service. The Department of Health also acknowledges that huge numbers with less severe problems are thought to need help that could be accessed through primary care, social care, early education and voluntary sector settings.

'Those receiving specialist care are a small proportion. A lot will get some kind of support from a trusted adult, a teacher or a social worker.

But most social workers and GPs have no interest in providing this type of care and certainly no training. They need the training to be able to pick up on problems and refer to specialist services if they are needed, ' says Gavin Bayliss, senior policy officer at Young Minds, a charity for the mental health of children and young people.

'Most young people would not even be in inpatient care if they had been treated earlier or were able to access a community service. If every primary school has someone trained in mental health interventions, they would be able to pick up a lot of kids.' The case for providing training for professionals working in non-mental health settings is strengthened by evidence that suggests services work best when they are not in a traditional setting.

'People do not find CAMHS user-friendly. We have strong research findings to suggest that services work best if they are not badged if they are delivered in generic settings, ' says Mr McCulloch, whose organisation has helped fund initiatives delivering services in places such as sexually transmitted infection clinics, because they are used by a lot by teenagers.

The organisation is currently looking for services that can be held up as best practice in delivering care to young people.

'You still need a tertiary service for 28 small amounts of high-quality care, but children and parents need services in the right time and the right place for them. Traditional services that are only provided 9 to 5 are no good because that is when mum and dad have to be at work. Hospital services are harder to access and more easily stigmatise the user.' But where badged mental health services are needed, there are simply not enough. It is estimated that only 50 per cent of trusts providing CAMHS have 24-hour or on-call teams. And the lack of inpatient beds for young people was recently highlighted by the Mental Health Act Commission, which found that 270 minors had been admitted to adult wards over a 17-month period. Three-quarters of those were emergencies.

There are thought to be just 600 CAMHS inpatient beds, and need is rising. 'About 10 years ago there was a decision made to disinvest in beds as it was felt levels of need could be managed within the community, ' says Suffolk Mental Health Partnership director of modernisation Alan Staff. 'At the time it was rare to see a young person with an acute mental health problem; it was more emotional crises and so on. But there is a growing number of young people presenting with acute illnesses, particularly in the later teenage years.' He adds: 'As we do not have a CAMHS on-call service here they get sent to a police station for assessment [which has to take place in 'a place of safety']. And it might take days for them to get help. It is appalling, really.' But Mr Staff says that admitting patients can be just as problematic: 'As the mental health national service framework says, under-18s should not be admitted to an adult ward. That puts pressure on inpatient beds too. Only a few units have the beds for them; the rest have to be sent out of area.' He admits that this can sometimes mean young people are sent to units hundreds of miles away from home, 'depending on where we can get a bed'.

'It is a complete postcode lottery. It is a resource-hungry environment, which also means we have to be tighter on referral criteria.' And there is not enough funding in place to do enough about it. The NHS planning and priorities framework for 2003-06 has said that a comprehensive CAMHS will be available in all areas of the service by 2006, but there are fears this will prove impossible.

'Things are improving, ' says Mr McCulloch.

'The national CAMHS implementation team are doing a bloody good job and we are seeing more staff. But the numbers just do not add up.' Lack of incentives to make it a priority to commissioners means funding has not been made available in many areas. Without a target to aim for, there is no incentive to put money into such services.

'CAMHS is a very small corner for hard-pressed primary care trusts and they are more likely to respond if the NHS trust has prioritised it. There is not much correlation between resources and need, ' says Mr Bayliss of Young Minds.

Mr McCulloch is in no doubt about the change in thinking that is needed before real improvements are to be seen in CAMHS. 'Neglect has allowed this to happen. Services need modernising.

'The DoH needs to talk turkey and talk about implementation plans, ' he says.

Find out more NSF for children, young people and maternity services:

www. dh. gov. uk/PublicationsAndStatistics Nuff ield Foundation

www. nuffieldfoundation. org Guidance on CAMHS mapping

www. camhsmapping. org. uk/2003/index. php Mental Health Foundation

www. mhf. org. uk Charity Young Minds

www. youngminds. org. uk Mental Health Act Commission www. mhac. trent. nhs. uk

Key points

Over 1 million under-18s would benef it from specialist mental health services, but they are lacking.

There is also a shortage of mental health inpatient beds for young people, and need is rising.

Comprehensive CAMHS is expected throughout the NHS by 2006, but there are fears this will be impossible.

WEST SUSSEX REACHES OUT

The primary mental healthcare workers team set up by West Sussex Health and Social Care trust has a simple aim: to reach children and young people before distress becomes a crisis. It is the first time such a service has existed in the area.

'It is a preventive and early intervention service to try and stop children from having to be referred to a specialist service, ' says lead primary mental healthcare worker Judy Andrews.

All the team is based in the community, in health centres, GP surgeries and family centres.

'We work with GPs, health visitors, school nurses and schools, signposting to other services in the community and doing training on mental health awareness. If we encounter more serious mental health problems they would be referred to a child and adolescent mental health service team, ' she explains.

Funding from the national CAMHS implementation team and five local primary care trusts led to a pilot of three workers for two areas in the north of the patch being set up in 2001, which was extended last year to a 10-strong team.

'We have quite small caseloads. We do a lot of joint assessments, and if caseloads were too large we might not be able to do the necessary developmental work.

Workers need lots of experience and therapeutic qualifications. They spend a lot of time working independently.' Ms Andrews adds that it is important the work her team does is carried out solely in the community.

'It is about the child getting the services they need when they need them. We will see them wherever is suitable; in a GP surgery, at home or at school. There is less stigma that way. It is also much easier for primary care staff to access us this way as they do not always understand what CAMHS does.'

WONDER WALL

INSIDE ONE INPATIENT UNIT

Wall Lane House is a 10-bed unit for 12 to 18-year-olds (patients must be in full-time education) run by North Staffordshire Combined Healthcare trust. It takes referrals from community CAMHS teams for patients with a range of disorders, both from their own trust's patch and out of area.

'Referrals include concern around low mood, self-harm, eating disorders or early-onset psychosis, ' says modern matron Melanie Allen.

The unit has been open since 1977 and has not had a waiting list for some time despite national shortages of inpatient beds for young people.

Patients are first admitted for an initial assessment of four to six weeks after which a decision is made on whether a further stay would be helpful, or if they should be referred back to a community team.

Lengths of stay average around three months.

Held up by the Mental Health Act commission as a good practice example of providing inpatient care, it says the unit had a 'warm and homely environment' and lots of age-appropriate facilities such as computer games and books'. The unit also has its own school.

'Continuing education is essential, ' says Ms Allen. 'Patients worry a lot about falling behind at school so they would be frantic with concern if we did not provide it.' The commission also found a wide range of therapeutic activities such as family therapy on site and a higher than average ration of qualified to unqualified staff.