Child and adolescent mental health services: A case study in confused priorities

This autumn has seen several government announcements giving greater priority to child and adolescent mental health services.

From greater scrutiny of how social media may affect a young person’s mental health, to the promise of additional CAMHS crisis teams to help reduce pressures on accident and emergency, the current focus on improving CAMHS care is commendable.

But in reality, these eye catching announcements will do little to deliver the meaningful expansion and improvements in care at the mental health provider level that young people need and deserve.

Audit results

A recent audit of child and adolescent crisis admissions (both under the Mental Health Act and informally) via A&E to CAMHS beds for patients living in the South London and Maudsley Foundation Trust catchment area (London Boroughs of Southwark, Lewisham, Lambeth and Croydon)  helps to demonstrate the increasing pressures facing CAMHS services at a trust level.

The audit showed that of a total of 71 child and young person crisis admissions via A&E to CAMHS beds between late 2015 and early 2018, 40 young people were admitted informally and 31 were admissions under the Mental Health Act.

Of these 71 cases, 44 (62 per cent) presented with self harm, suicide or extreme emotional dysregulation, and most of the other patients who were admitted presented with psychotic illnesses.

White British patients were the largest racial group admitted in totality as crisis admissions to CAMHS beds. However, Afro-Caribbean patients were the largest racial group (18 of 31) admitted under the Mental Health Act. Many of those attending A&E had little or no previous contact with CAMHS services.

The time from attendance at A&E to being admitted to a mental health bed for some of the most unwell young people presenting in mental health crisis appears to be increasing

Prior to 2017, there were 38 patients admitted to CAMHS beds following crisis admission, of which 30 went to beds within the trust catchment, one to a bed elsewhere in London, and seven patients were admitted to beds outside of London.

However, in 2017 and early 2018 local bed pressures in South London increased, and of the 33 patients admitted in crisis to CAMHS beds via A&E, only 17 went to beds within the trust catchment area, six to beds elsewhere in London, and 10 patients were admitted to beds outside London; in some cases, hundreds of miles from their homes and families.  

The time from attendance at A&E to being admitted to a mental health bed for some of the most unwell young people presenting in mental health crisis appears to be increasing. From 2017 onwards it took almost 4 days (mean time 87 hours and 28 minutes) to access a CAMHS bed when a patient was admitted under the Mental Health Act, compared to just over 2 days (mean time 54 hours and 55 minutes) before 2017.

Many of the problems facing CAMHS and also learning disability services including the bed pressures identified in the Maudsley crisis admissions audit are symptomatic of the wider challenges facing mental health services.

Shrinking workforce and reduced number of beds

When the number of mental health beds in England has fallen by over 25 per cent between 2009 and March 2018 from 26,448 to 18,082, it is little wonder that a trust audit is evidencing challenges in finding local bed availability in a timely manner.

The number of (FTE) mental health nurses has also fallen by 6,026 between 2010 and March 2018, with a reduction of 1,832 learning disability nurses alone during that period.

The number of CAMHS and learning disability consultant psychiatrists has also slightly declined over the past decade and many parts of the country (particularly outside London) are struggling to fill higher (registrar) training posts in CAMHS and learning disability psychiatry.

Perhaps more concerning is that the number of junior doctors in specialist psychiatric training (core and higher psychiatry trainees) who will become the consultant psychiatrists of tomorrow, have also fallen by 490 (FTE) from 3,187 in 2009 to 2,697 in March 2018.

Healthcare apps and talk of fines for social media companies are no substitute for having enough trained professionals on the ground to deliver frontline care for young people

Recent positive rhetoric on child and adolescent mental health still bears little resemblance to the reality facing many children and their families.

With a shrinking CAMHS and learning disability workforce, it is difficult to see how current levels of care can be maintained, let alone the step change in mental healthcare for young people that has recently been announced, be realised.

Healthcare apps and talk of fines for social media companies are no substitute for having enough trained professionals on the ground to deliver frontline care for young people and their families.

Underfunded community services

The NHS is too often viewed through the prism of A&E, and as a result acute hospitals often receive a disproportionate level of funding compared to primary care and community services.

In child and adolescent mental healthcare, as in other parts of the NHS, community services are often understaffed and poorly resourced.

Without enough frontline staff to deliver care, community CAMHS services can often only provide a threadbare service. Despite the best efforts of staff, there remains a lack of resources (both financial and staffing) available for the early intervention work with schools and in the community that could help prevent crisis attendances and admissions to A&E.

Without enough frontline staff to deliver care, community CAMHS services can often only provide a threadbare service

If we are to improve child and adolescent mental healthcare, the government would do well to properly analyse the problem and to acknowledge the scale of the challenge.

This work must begin with providing the funding to increase the number of CAMHS beds in some parts of the country including London, and crucially, providing the necessary recruitment and retention incentives to considerably increase the number of NHS staff working with children and young people with poor mental health.