A few days after publication of Dr Susan Finnerty’s damning report on Child and Adolescent Mental Health Services (Camhs) in late July, I bumped into an old friend who worked in mental health services for 30 years. I greeted him: “So, what do you make of the Camhs report?” Rolling his eyes to heaven, he replied: “Tell me something I don’t know.”
The pervasive shortcomings in the organisation, management and governance of Camhs documented by Dr Finnerty have been known for decades to anyone acquainted with the system.
Practically every element of a functioning organisation is absent or deficient. There is no clear leadership of Camhs at the apex of the system. Though long overdue, the appointment of the first ever clinical lead for youth and mental health and the creation of a dedicated National Office for Child and Youth Mental Health by the Minister of State for Mental Health and Older People, Mary Butler, are to be welcomed. So too is Dr Finnerty’s recommendation that there be immediate external regulation and oversight of Camhs by the Mental Health Commission.
It represents a serious indictment of senior Health Service Executive managers, civil servants and successive ministers for health that this kind of basic leadership and oversight infrastructure are missing. Such gaping holes at the apex of any organisation inevitably result in the litany of shortcomings cited by Dr Finnerty – including poor local governance, as in South Kerry where serious harm was done to children; no specified standards applied consistently across the service; poor risk management; no performance measurement and monitoring template; lack of administrative support; and lack of ICT, as a result of which hundreds of children “got lost” in the service.
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An Irish Times editorial published last month quoted Children’s Ombudsman Dr Niall Muldoon’s charge – in his letter to the HSE – that there are too many siloed agencies “who do not and apparently will not work together to ensure the best interest of the children they are charged to care for”.
Shortcomings in organisational infrastructure in Camhs and related agencies have terrible consequences.
Parents despair, feeling isolated and abandoned, especially if they are poor. Children suffer long-term harm. Staff either burn out, cope heroically as best they can or opt out.
Public relations cycle
And what is the response of senior HSE managers, senior civil servants and Government Ministers to this recurring drumbeat signalling extreme distress in our mental health services? Or to similar cris de coeur from children being slowly crucified with pain as they wait years for scoliosis treatment?
They manage a 48-hour public relations cycle, try to ride out the storm with unfortunate spokespeople offering “sincere apologies for anyone affected” and declaring that “we are committed to providing the best possible service” while reassuring us that “the recommendations in the report are already being addressed” (which they rarely are). And then the issue goes on the back burner until the next shocking revelations.
The Government is patently not committed to providing a high-quality service.
Money is a good indicator of commitment, and the Minister of State says she has secured an extra €200 million for Camhs. However, the proportion of Ireland’s total health budget allocated to mental health services fell from 6 per cent in 2020 to 5.1 per cent in 2022. In France the corresponding figure for 2020 was 14.5 per cent; and in the UK it was 13.5 per cent. Every year, Mental Health Reform publishes these comparisons in its pre-budget submission, but little has changed to shift the Cinderella status of mental health services.
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The forthcoming budget provides a golden opportunity to do the right thing by children, not just in mental health services but across the whole spectrum of child poverty, disability, sickness and disadvantage. As Fintan O’Toole urged the Taoiseach in these pages: “No more tinkering, big changes demand big decisions.”
Pouring money into a broken system will not solve the problem unless the inherited systemic shortcomings are effectively addressed
The recent announcement about recruitment of the six regional executive officers (REOs) to head the new regional health organisations, as recommended six years ago by the all-party Sláintecare report, is a vital chance to bring about the deep reforms required to deliver the integrated services for children urged by Finnerty and Muldoon. Crucially, the Government must stipulate the proportion of regional budgets to be allocated to these services, as well as insisting on clear structures of accountability and top table positioning within each regional structure.
Because of poor organisational infrastructure across the HSE, managers are on a treadmill, coping with endless pressure and crises. As one put it: “We spend all day shooting crocodiles, so we never get around to draining the swamp.”
It is imperative that managers assigned to transforming mental health services are not just competent troubleshooters but also know how to drain the swamp – and are given the resources and authority to do so. They will require the same unflinching Government support that Mary Harney gave to Prof Tom Keane to rationalise cancer care services, because they will meet fierce resistance from vested interests. Pouring money into a broken system will not solve the problem unless the inherited systemic shortcomings exposed, once again, by Finnerty and Muldoon are effectively addressed.
Dr Eddie Molloy is an independent management consultant and co-founder and former chairman of Mental Health Reform