Hard to Feel Hopeful

CAMHS services are on a downward curve and new ‘throughput’ policies will make life harder still for young people in difficulty, writes David Jenkinson.

Getting referred to a child and adolescent mental health service (CAMHS) has never been fun. It means something drastic is happening at an already difficult time. Not only is it hard for the young person themselves, but it is also hard for that person’s family, for their peers, and for the other professionals who have a responsibility to them. Mental health problems in young people are often hard to understand. It is often hard to be helpful, and it is sometimes impossible to keep hope alive.

NHS Scotland has been providing specialist services for children and young people’s mental health since about the mid-1980s. It started when a few chaotically organised Child Psychiatry Clinics came into being (in Scotland, at least) because of the enthusiasm and passion of various Consultant Psychiatrists and their colleagues, not because they were commissioned. They grew in Edinburgh, Glasgow and in Aberdeen and Dundee some time after. A team would be a consultant and a few keen social workers. Nurses came later, psychology even later than that.

The idea of ‘commissioning’ a Child and Adolescent Mental Health Service (CAMHS) came later still. In Scotland, some health boards still haven’t really commissioned their CAMHS provision, and instead have just configured what they already have. Funding has always, always been an issue. There have only been a few short periods in my time in CAMHS teams where we felt as though we were managing well. I often heard politicians talking about increased spending in CAMHS, but I can tell you that at times it was hard to believe that any new money was coming our way. Sometimes the funding was for fixed-term projects that helped, a little bit, but just for the fixed term. In any event, for every £10 NHS Scotland currently spends, less than 10p is spent on child and adolescent mental health. The bottom line is that whenever we look, we see unmet demand. We’ve known for a very long time that the incidence of mental health problems in the population under 18 that require some kind of intervention to resolve has been about one in ten. Recent evidence suggests that the ratio had increased to one in six. That means an average sized classroom might have five or six desperately unwell individuals in it. Our colleagues in social work, starved of funds themselves (because the spending bias has been slightly towards health since prior to the credit crunch in 2008) have effectively closed their doors to young people who have a ‘mental health’ component to their difficulties. The idea of joint, multi-agency working seems a long way off for most CAMHS clinicians. Our colleagues in education and in the police are increasingly becoming front line mental health workers themselves. It is hard to feel hopeful for the future.

With the CAMHS systems already stressed, it is clear that something is happening to young people’s mental health. The impact of the pandemic is still to be fully realised but we know that in recent years, the number of young people looking for help has skyrocketed. There has been an increase of 80% in eating disorder presentations. We know that there is no mental health presentation with a higher mortality, and that so far, no matter what we do, we can expect that 1 in 10 of children diagnosed with an eating disorder before they are 16 will ultimately succumb to the consequences of prolonged starvation, or will take their own lives. So the fact that there are now many more individuals with eating disorders is grim news.

We know that poverty makes you ill – so young people living in desperately poor circumstances brought about by austerity won’t live as long, and will be unwell in one way or another for a greater part of their lives. The same is true of trauma. We know that trauma damages the developing brain, and we know that good therapy can help people rebuild their lives. Without good therapy, the ‘adverse childhood experiences’ leave many people carrying the awful traumas of childhood into uncertain, but invariably unhealthy futures.

Most CAMHS managers know that you can’t beat the curve. Making mental health services available to the extent they are needed will cost a lot of money. But as long as CAMHS, with a clinical responsibility for the mental health of the population under 18 (about 20% on average), is only getting 5% of the budget, we can’t possibly catch up.

Instead, managers want to increase the ‘throughput’ so that more people are seen. For a long time, those working in CAMHS teams operated on the principle established by the Royal College of Psychiatry in the early 2000s that the maximum safe number of ‘new’ young people to be seen in a year was about 40, about one per week. This took into account the fact that young people often need several appointments to ‘warm up’ to therapy, and that their presentations were often much more complex and difficult to grasp when compared to work with adults. But somehow, that ‘maximum’ became a ‘minimum’. We dropped the principles of multi-disciplinary, then joint, assessments not because the evidence told us that such things weren’t necessary, but because getting a lone practitioner to assess a young person newly presenting to CAMHS was cheaper. We made it harder for young people to get an appointment, putting in screening processes that, subtly or otherwise, told our young clients that they weren’t yet sick enough. Even if you eventually do get an appointment (about half of all referrals to CAMHS are rejected), CAMHS managers are placing worried and exhausted practitioners under pressure to discharge young people after six sessions or so, just aiming for them to be ‘well enough’ to allow us to forget about them for a while. They are being forced to ration something that is already rationed. And it’s the young people, their families, and those trying to help them, that pay.

But something has kept me in CAMHS, and in the NHS throughout a lengthy career. It’s mostly the people. Despite the many challenges, I’m constantly amazed to be working with people who consistently strive to do a better job tomorrow than the one they did yesterday. We are getting better at thinking about how we can look after those charged with the huge task of keeping vulnerable and challenging young people safe and well. My own health board seems to be particularly committed to this. I’m also amazed by the resilience, strength and humour the young people themselves show time and time again. They have been beaten up by life, but they get back up. It is humbling to be with them, and nothing beats the joy when a young person is discharged from your care to a hopeful future. We just want to be able to do that more often.