HSE child mental healthcare: Inspector ‘cannot assure parents that services are safe and effective’

Parents seeking mental healthcare for their child cannot be assured HSE services are “safe, effective, and evidence based”, chief inspector of mental health services has warned.

Dr Susan Finnerty, in a blistering report, says the Child and Adolescent Mental Health Service (Camhs) “is creaking at the seams, with increasing risk to children for whom the service is provided”.

It is led with “poor governance”, characterised by “failure to manage risk, failure to fund and recruit key staff, failure to look at alternative models of providing services ... and the failure to provide a standardised service”.

The 145-page report, published on Wednesday, finds staff are burnt out, working beyond contracted hours and do not feel supported. The “distress and frustration of families ... trying to access a Camhs service or any mental health service for their child, was profound”.

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The Independent Review of the provision of Child and Adolescent Mental Health Services looks at the service across all nine Community Health Organisations (CHOs).

It follows Dr Finnerty’s interim report that was published in January due to her grave concerns about what was emerging in the five CHOs that had been inspected so far.

At that point Dr Finnerty called for “immediate regulation” of the service under the 2001 Mental Health Act due to “serious risks to the safety and wellbeing of children” engaging with it.

Regulation of Camhs would empower the Mental Health Commission, which regulates and inspects mental health services in Ireland, to take enforcement action against its providers – primarily the Health Service Executive (HSE), where its failings put children at risk.

Dr Finnerty reiterates this call in this final report: “to ensure the State and the HSE act swiftly to implement the governance and clinical reforms” to ensure “all children have access to evidence-based and safe services, regardless of geographical location or ability to pay”.

The review began after last year’s report from Dr Seán Maskey on South Kerry Camhs that found 240 children received substandard care and 46 were harmed.

Wednesday’s publication comes as the first legal case arising from the South Kerry Camhs crisis was concluded at the High Court on Tuesday, with settlement of €92,500 in the case of a 15-year-old boy who was alleged to have suffered personal injuries due to the way medication was prescribed and an alleged failure to adequately monitor the effects of prescribed medication.

The full report gives further evidence of findings published in January.

It finds staff who “worked extremely hard to try to provide a good Camhs service” and “many young people and their families have received excellent care and treatment”.

However, Dr Finnerty writes: “I cannot currently provide an assurance to all parents or guardians in all parts of Ireland that their children have access to a safe, effective, and evidence based mental health service.”

The vast majority of teams “were significantly below the recommended staffing levels” with some below 50 per cent of recommended level. There were particular shortages in occupational therapists, social care leaders, advanced nurse practitioners, clinical nurse specialists, psychologists, speech-and-language therapists and social workers, while in five CHOs no team had a team co-ordinator, the report says.

Some teams had no consultant psychiatrist – the post that leads teams – with this post covered by rotating consultants or locums “which has implications for ... continuity of care”. Telepsychiatry, including from the Middle East, was used in a number of areas. “This patchwork of cover increases the risk of poor care” says the report.

“We met staff who were working beyond their contracted hours, who were burnt out and frustrated by not being able to provide at the time of our review, what they saw as a safe and effective service.” The report finds “no evidence [of a] national co-ordinated approach” to tackle this.

There were “unacceptable variations” in care depending on location, with for instance only some teams offering parenting groups and play therapy available in “only a handful” of areas.

“It is difficult to see this as anything except a postcode lottery for children and their families ... This means inequalities of care ... which should be seen as unacceptable”.

Camhs receives an estimated is €137 million, or some 12 per cent of the overall mental health budget, says the report, despite 24 per cent of the population being aged 18 and younger – the youngest population in the European Union.

There were “deficits in ... risk management” and risks going unidentified “due to a lack of auditing and review”. The lack of action or feedback when risk was reported so frustrated some teams “they told us that they did not ‘bother’ to escalate risk any more as there was no point”.

Inspectors found that one team had 140 “lost” cases – where children were left without follow-up and their cases ‘lost’. These had been identified by the HSE before the inspectorate’s review and all 140 children had been contacted “and no adverse impacts have been identified for any”, a HSE spokeswoman said.

“Another team in another CHO did not follow up their patients for up to two years despite these children being on continuing medication,” the report continues.

There was “a large, unacceptable variation in both the number of children on waiting lists and the length of those waiting lists” and in the “acceptance of referrals, which varied between 38 per cent and 84 per cent”.

Dr Finnerty’s inspectors spoke to 43 families and nine young people, for whom the “most frequent issue” was difficulty accessing Camhs.

“They expressed concern at how their child deteriorated while waiting for an assessment. Parents did not know where they can get help and information ... and felt that a crisis needed to be reached before appropriate services are offered ... or that they have to battle with services before help is provided.

“Many of their children were out of school, or spent long periods away from school and were not interacting with peers,” Dr Finnerty adds.

“Some parents said that they were told that if they did not consent to their child taking ADHD medication that they would be discharged without further input.”

In her concluding remarks Dr Finnerty says: “The HSE is clinging to old models of service provision that do not adequately meet the needs of young people and are different from models in other similar countries.

“It is obvious that staff shortages will continue and that it will be impossible to safely staff many teams, yet there is little consideration given to looking at alternative models of service provision that would lessen the impact of staff shortages on children and young people.”

She says the model, whereby Camhs teams can only be led by a consultant psychiatrist, is unsustainable where there is a global shortage of these professionals. “The HSE rigidly maintain staffing models that are 16 years old and workforce planning that makes no sense in modern CAMHS, and stick to siloed provision of mental health services for children.

“These services are propped up by injecting boluses of money when crises occur, working staff to the point of burnout, blaming retention and recruitment difficulties, reacting to crises rather than trying to prevent them by good governance.”

Dr Finnerty makes 49 recommendations, under nine headings, including governance, risk management, staffing and access to Camhs. Among them is that their implementation “must be monitored by the Mental Health Commission, who must publish a yearly report on ... progress”.

Responding to the report, Dr Niall Muldoon, the Ombudsman for Children, said he was “deeply concerned” about the lack of assurances over the safety of services.

“This is a dangerous and truly unacceptable situation for our children and young people,” he said.

The ombudsman, who acts as a watchdog for children’s rights, said the current Camhs model of care based around a single consultant psychiatrist was “outdated”.

Dr Muldoon said the present system could “no longer be considered fit for purpose”.

Dr Patricia Byrne, chair of child and adolescent psychiatry at the College of Psychiatrists of Ireland, said there was “no time to waste” addressing failings.

There needed to be an “extensive” national recruitment campaign to hire more staff, to ensure all teams were properly staffed, she said.

Damien McCallion, HSE chief operations officer, acknowledged the report and a previous interim report had exposed “deficits and shortcomings in the service” provided to children and families.

“While investment in Camhs and youth mental health service improvement has grown over the past decade, we know improvements still need to be made and we are determined now to make substantial changes and improvements,” he said.

Reforms included a new HSE youth mental health improvement programme, under a new national office for Child and Youth Mental Health.

David Cullinane TD, Sinn Féin’s health spokesman, said the report was a “damning indictment” of how the Government was failing young people.

“Government failure to protect vulnerable young people is not new news – it is something that concerned parents have been highlighting for a long time now,” he said.

Lengthy waiting lists for mental health services meant chances for early intervention was “passing our young people by”, which he said was “unacceptable”.

Minister of State for mental health Mary Butler said she had been assured that “all immediate concerns” raised in the report were being addressed “as a matter of priority” by the HSE.

Tanya Ward, chief executive of the Children’s Rights Alliance, said it was “unacceptable” than an effective “postcode lottery” determined the quality of mental health services children received.

Dr Anne Kehoe, president of the Psychological Society of Ireland, said its members worked to deliver the best possible outcomes for every child.

However, she said frontline workers were seeing “traumatised children entering a traumatised system” that was failing to meet their needs.

“We need minimum safe staffing levels for Camhs teams to operate under, similar to the system used in acute inpatient units,” she said.

The Psychiatric Nurses Association (PNA) has described the report as extremely worrying but not surprising.

PNA General Secretary, Peter Hughes, said: “As a union representing nurses at the frontline of CAMHS, PNA has for some years now pointed to the lack of investment and staff resourcing in the services. We have highlighted again and again the often-intolerable pressures and frustrations for those staff left to cope with vacancies and staff shortages. Today’s Review confirms how widespread and endemic these failings are across all levels of the services.”