National Assembly for Wales
Children, Young People and Education Committee
CYPE(4)-08-14 – Paper 1 – Royal College of Psychiatrists
Inquiry into Child and Adolescent Mental Health Services
The Royal College of Psychiatrists is the professional medical body responsible for supporting psychiatrists throughout their careers, from training through to retirement, and in setting and raising standards of psychiatry in the United Kingdom.
The College aims to improve the outcomes of people with mental illness, and the mental health of individuals, their families and communities. In order to achieve this, the College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers and their organisations. Nationally and internationally, the College has a vital role in representing the expertise of the psychiatric profession to governments and other agencies.
Royal College of Psychiatrists in Wales is an arm of the Central College, representing over 550 Consultant and Trainee Psychiatrists working in Wales.
For further information please contact:
Ms Manel Tippett
Policy Administrator
Royal College of Psychiatrists in Wales
Baltic House
Mount Stuart Square
Cardiff Bay, CF10 5FH
029 2048 9006
www.Royal College of Psychiatrists.ac.uk
@Royal College of PsychiatristsWales
The Royal College of Psychiatrists in Wales are pleased to respond to the call for evidence on the Committee’s inquiry into CAMHS in Wales. Whilst there have been some improvements in CAMHS over recent years as highlighted in the recent Wales Audit Office report, this does not negate the need for scrutiny into where we are failing to meet the needs of this vulnerable group. The College has collected the views of our Members across Wales and our response on the pages below reflects these in general terms. We are happy to provide more detailed information during the hearings.
In this current economic climate and continued age of austerity, the lack of resources and the financial constraints along with increased demands have impacted all sectors, and many public services continue to work under capacity. This is also true of CAMHS. There is further pressure placed on these services with the implementation of the Mental Health Wales Measure (The Measure) and the unintended consequences of it and also the increased burden on CAMHS due to extension to 18th birthday from April 2012. However, we feel that despite financial and legal constraints, we can make improvements if we focus on further strengthening the ties between the NHS and social care in order to provide more holistic care to children and young people.
If you have any queries, please do not hesitate to contact the College on the number above. We look forward to working closely with the Committee on this inquiry and in the future.
Dr Alka Ahuja, Chair of Child and Adolescent Psychiatry
Royal College of Psychiatrists in Wales
The availability of early intervention services for children and adolescents with mental health problems;
1. Early detection and intervention are part of the preventative agenda, which encompasses universal, targeted and indicated preventative responses. The services designed to meet this agenda work with varying levels of success throughout Wales, in particular those involved with widened remit early intervention CAMHS work with the tier 1 and 2 services (Teachers, Social Workers, General Practitioners, Primary Mental Health Support Services Practitioners, Third Sector workers etc) at the universal and targeted level.
2. The introduction of the Measure has resulted in several changes in CAMHS with respect to early intervention and prevention and the reconfiguration of primary mental healthcare teams.
3. A recent audit of the Wales Primary Mental Health Group highlighted CAMHS as one of the biggest gaps in their competencies. We note that teacher training and Social Work training have no child development or mental Health component.
4. We would like to highlight good practice being rolled out in some areas in Wales where there are appropriate early intervention and prevention services integrated with the locality specialist community CAMHS.
5. Bilingual Websites for children and young people such as Mental Health Matters are now available in many schools.
6. Royal College of Psychiatrists (UK) is involved in the creation of MindEd an online education resource for professionals from all backgrounds who interface with children and young people. This launches in March 2014.
Access to community specialist CAMHS at Tier 2 and above for children and adolescents with mental health problems, including access to psychological therapies;
7. Providers of services to children with mental health problems report they have experienced an increased amount of bureaucracy with the introduction of the Measure, which has impacted negatively on the time spent with patients and on timely access to community specialist CAMHS. In some areas this has reduced the capacity of frontline services. This may be reasonable if there is evidence that this has improved the quality of services to children and young people. It would be helpful if this could be evaluated.
8. Following introduction of the Measure, some areas in Wales have re-prioritised their response to referrals to those meeting threshold for Part 2 of the Measure which appears to have raised the threshold for referrals seen.
9. Some areas have Early Intervention Psychosis teams whose remit crosses the age divide and is appropriately needs-based rather than age-based. CAMHS have close links with such teams resulting in better management of first episode psychosis resulting in the decrease in the duration of untreated psychosis.
10. We are concerned that access to psychological therapies is patchy. In some areas there is good integrated provision of a range of psychological therapies within specialist CAMHS. In other areas provision is very restricted. Availability and accessibility is very variable in across Wales.
The extent to which CAMHS are embedded within broader health and social care services;
11. We feel in general there is not an effective integration of CAMHS and social care services in the delivery of care to children and young people. This has not been helped by the budget constraints evident in the Local Authorities. The extent to which CAMHS is embedded in the broader health and social care services varies throughout Wales. Despite some good working relationships between CAMHS and social services in some local authority areas this often depends on individual relationships in a locality. And in other areas despite good locality relationships between CAMHS & Social Services, there is currently less joint multi-agency planning at a strategic level.
12. We still have a problem in Wales that CAMHS provision is seen to be the sole task of the NHS provided CAMHS team. The message that it is everybody’s business is often missed. This greatly limits the access of children to services that can support their emotional health and wellbeing (early intervention and preventative services). In some areas as a result of the local authority budgetary problems, Special Educational Needs services and services to Looked After Children have been reduced and the Local Authority has looked to specialist CAMHS to fill resultant gaps.
Whether CAMHS is given sufficient priority within broader mental health and social care services, including the allocation of resources to CAMHS
13. Some Health Boards have given priority to resources in specialist CAMHS in line with directive from Welsh Government, and CAMHS have received allocation of monies from, for example, Mental Health Measure implementation funding. However, pressures from Acute Health Care in other specialities frequently detract from appropriate specialist CAMHS resourcing. Other Health Boards have not given appropriate priority and in these areas specialist CAMHS continues to work under capacity.
Whether there is significant regional variation in access to CAMHS across Wales
14. There is significant variation in access to CAMHS across Wales. For example:
· The existence of intensive social service or 3rd Sector-funded therapeutic teams to meet wider psychosocial needs of children and young people with emotional and/or behavioural difficulties.
15. Some specialist community CAMHS teams in Wales currently have a workforce approaching national benchmarking and Royal College of Psychiatrists recommendations. However, even so there are still some problems in access times, and any reductions in workforce caused by sickness, vacancy control or redeployment results in a significant reduction in capacity impacting negatively on the ability to maintain a timely high quality service. Other areas in Wales have a workforce that lacks the capacity and requisite multi-disciplinary skills to deliver effective evidence-based interventions. Some areas have workforce capacity significantly lower than those recommended by national benchmarking.
16. This is further complicated by the introduction of the Measure, which has forced an unhelpful re-organisation of the workforce in some areas. Experienced mental health practitioners with a background in paediatric nursing or mental health therapy are no longer able to carry out autonomous mental health assessments or act as Care Co-ordinators. This has resulted in a reduced clinical capacity in some teams.
17. We believe that models of service provision must be designed and financed to fit rural areas such as Powys, as well as urban parts of Wales. This is particularly important for the most unwell children who need specialist skills and intensive resources including Tier 4 CAMHS intensive outreach and inpatient beds.
18. We think the sustainable effective provision of specialist CAMHS in Wales is suffering from a lack of co-ordinated commissioning of services.
The effectiveness of the arrangements for children and young people with mental health problems who need emergency services;
19. In most areas of Wales, emergency presentations within routine working hours are responded to the same day. Most areas of Wales have a specialist CAMHS out-of-hours service but the comprehensiveness of these services varies. In some areas the Consultant Child & Adolescent Psychiatrist is the first on call out-of-hours and provides telephone support and advice for adult psychiatry and paediatric doctors. In other parts of Wales there is no out-of-hours specialist CAMHS cover.
20. The CAMHS liaison pathways for self harm/suicidality, eating disorder and other emergency mental health presentations are compromised in many areas by insufficient capacity and/or a lack of joint planning by partner agencies to create joint protocols to fully meet the medical, social and safeguarding needs, as well as the mental health needs of children and young people.
21. An unresolved area of concern in many areas is identifying an appropriate place of safety for young people detained under section 136 of the Mental Health Act.
22. For crisis presentations of children and young people with a combination of social, safeguarding and mental health risk there is frequently a lack of clarity as to which practitioners from which agency will take the lead responsibility for assessment and management of the case. This can lead to an unco-ordinated or unhelpful response which is not in the young person’s or the family’s best interests at a time when services should work together to meet complex needs.
The extent to which the current provision of CAMHS is promoting safeguarding, children’s rights, and the engagement of children and young people;
23. Safeguarding mechanisms, training and reporting structures are in place in most places.
24. Engagement of hard to reach young people and families is something most services prioritise and put much resource into. Many services have adapted their Local Health Board DNA policies to facilitate this.
25. There is still work to do to fully engage children and young people, and their families, in the design and development of services. There are services where children and young people are actively involved in service development and in staff training. This needs to be rolled across Wales.
26. There are areas of excellent practice in specialist CAMHS in Wales, but we think that social care and specialist CAMHS could be much more integrated in their approach to the work with children and young people with mental health needs, both in early intervention and for those in crisis.
Other Issues:
Problems of access to CAMHS for children with Intellectual Disability:
27. There is a paucity of services for children and young people with Intellectual Disability. The response to the direction from the Government for CAMHS to provide specialist CAMHS learning disability services appears patchy. Some areas have designated CAMHS-LD services, but in other areas specialist CAMHS provision for Children with intellectual disability is largely through liaison to Special Schools. Therefore perpetuating gaps such as care for young people who have left school or who have been excluded. Where they exist, most CAMHS-LD services appear to lack sufficient resources around behavioural assessment and modification. Consequently psychiatrist colleagues working in adult intellectual disability report that young people transition to adult services with deeply ingrained maladaptive patterns of behaviour that impact on their quality of life. There is further concern that when local services are unavailable those with the most problems must move to specialist educational provision distant from their homes.
28. The transition process for young people with intellectual disability often does not take place within the statutory framework. We would welcome scrutiny of the current system of automatic transfer of young people with Intellectual Disability, including those with co morbid conditions such as Autism Spectrum Disorder, to Specialist Residential Colleges
29. There is confusion and inconsistency over the extent of assessment provided by CAMHS services to children and young people with intellectual disability out-of-hours, even where there is an on-call rota
Transition arrangements:
30. Across Wales there are patchy arrangements for transition from CAMHS to AMHS and a paucity of comprehensive services for youth. This is an ongoing problem which requires further exploration and implementation of effective solutions.
31. NICE is beginning to scope guidance on transition from Children’s to Adult Services across health and social care in England and Wales.
Treating the Parents with Mental Health disorders:
32. CAMHS relies on adult mental health services to treat parents with mental health disorders. This is a particular issue for parents with personality disorders, who may be seen as needing services under part 1 of the Measure for their own mental health but need much longer and complex interventions if their parenting is to change sufficiently to improve the mental health of their children. We would support the development of effective multi-model services for adults with a diagnosis of Personality Disorder
CAMHS inpatient Beds:
33. There is an absence of beds for particular groups of children and adolescents in Wales. There are currently no adolescent PICU (Psychiatric Intensive Care Unit) beds in Wales, no CAMHS–Learning Disability beds, no Adolescent Forensic beds and no specialist CAMHS beds for children under 12 years.
Admissions to Paediatric and Adult Mental Health wards.
34. We recognise that safeguarding issues, mental health need and developmental stage must be taken into account when admitting a child or young person with mental health problems to hospital.
35. Most LHBs have a protocol for the management of Self Harm presentations of under18 year olds to the District General Hospital. Good practice routinely involves the admission of a young person to a paediatric ward with referral to specialist CAMHS the following day. This group of young people rarely need admission to a psychiatric inpatient unit. Integrated assessment and management by paediatric team, specialist CAMHS and social care is required. This usually results in timely discharge home. The effectiveness of these processes varies across Wales.
36. We strongly support the view that children admitted to hospital for treatment of a mental disorder should, subject to their needs, be accommodated suitably for their age. The Mental Health Act 1983 Code of Practice for Wales states that “If exceptionally this is not practicable, discrete accommodation in an adult ward with facilities, security and staffing appropriate to the child’s needs might provide a satisfactory solution”. “In a few cases, the child’s need to be accommodated in a safe environment could, in the short term take precedence over the suitability for age. It is important to recognise the clear difference between a suitable environment in an emergency and a suitable longer-term environment for a young person”. The Child & Adolescent Faculty of the Royal College of Psychiatrists in Wales is keen to ensure that inappropriate admissions to adult wards do not take place, and that if a young person under 18 years is admitted to an adult bed that they are assessed promptly by a CAMHS practitioner who ensures that appropriate discharge or transfer to an age appropriate bed takes place promptly according to clinical need. We think the need for admissions such as these should be rare. We would welcome a robust, reliable process to ensure these events are recorded and fed back within LHB structures to facilitate close monitoring. We would welcome planning and investment that ensures that every child and young person in Wales has equitable access to age appropriate inpatient beds and an “Alternative to Admission/ Intensive Outreach Team.” We think this would reduce the need for inappropriate admissions to adult or paediatric wards.
37. We recognise there is a lack of integrated health and social care crisis/respite placements in Wales for children and young people whose risk is related to safeguarding and/or behaviour issues. We would welcome consideration of planning and investment in this area.
CAMHS liaison pathways for self harm/suicidality:
38. We would welcome a review of the need for CAMHS Liaison services for children and young people presenting to the acute general hospital with mental health disorders.
S136 Places of safety:
39. There is a need to identify appropriate places of safety and clear protocols of care for under 18 year olds placed under S136 of the Mental Health Act.
Substance Misuse:
40. More must be done to address the needs of children and adolescents with substance misuse. We are concerned that there is a paucity of effective, integrated substance misuse services for children and adolescents across Wales.