Sir, – The interim report of the Mental Health Commission (MHC) on the HSE Child and Adolescent Mental Health Services (Camhs) was published this week and is welcomed. It is unarguable and inexcusable that children and teenagers suffering from moderate to severe mental illness requiring evidenced-based, multimodal, psychiatric treatment with psychotropic medication, a necessary component for most, have for years been subjected to a HSE service that is not fit for purpose. That this report is published only now, 21 years after the formation of the MHC, having been requested for years, is emblematic of the factors that have led to this situation.
There is very little in this report that was previously unknown to those who listened or cared. Countless communications have been made by ourselves and consultant colleagues highlighting risks, service inequity, unacceptable wait times and recommending evidenced-based solutions to relevant HSE and Department of Health personnel.
Nothing happened.
A recurrent theme in the commentariat’s analysis of the fallout from the report has been the distress induced by listening to the compelling narratives of the brave parents who have shared their stories. The collective emotional load borne by parents in these situations is incalculable and unforgivable. It is worth also considering what it is like for those of us charged with delivering HSE child and adolescent mental health services at the coal face listening and living this distress every day while trying to treat the underlying psychiatric illnesses without access to requisite resources or evidenced-based treatment options in the near-absence of any relevant community supports or inpatient beds while being acutely aware that all associated risk will rest on our shoulders alone. All this against the backdrop of a HSE system that refuses to even acknowledge consultant communications desperately trying to highlight concerns. The unprecedented levels of burnout documented in child and adolescent psychiatrists nationally is a testament to the toll that the moral injury of working under these conditions exerts. The attendant recruitment and retention crisis is set to worsen. If the inertia of the HSE approach to date continues, services will effectively cease to function.
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The deficiencies in the execution of HSE governance of child and adolescent mental health services cannot be overstated, and it is of serious concern to us that the MHC report downplays the reality and critical impact of what amounts to shambolic leadership on the day-to-day resourcing and delivery of services. The absence of out-of-hours services, child psychiatry admissions, adequate educational psychology services, unprecedented delays in access to assessment of need (with a number of cases in court this week), lack of autism, early intervention and disability services, together with delays in access to adult mental health services when teenagers turn 18, against the backdrop of dramatically increasing prevalence of mental distress, fuelled further by the pandemic has led to a well signposted “perfect storm” which would overstretch even the best performing services.
Is the proposed audit of 20,000 case files the answer? Fiddling and burning come to mind. There is no national or international precedent for such an approach. Without a transparent, scientific explanation as to the objectives of such an exercise and a clear outline of how the auditing group has been convened and expertise in paediatric psychopharmacology determined, it is very difficult to appreciate what this exercise can reasonably achieve. Given that an exercise like this has never been carried out, there will be an absence of scientific literature to inform the process. A scoping review of the scientific literature will undoubtedly be required to ensure that there are at least some scientific standards being applied. All of this will take huge resources and time. All 20,000 patients’ parents/guardians will have to be contacted to ensure informed consent and the exact parameters being audited will require clear explanation to all parents/guardians in advance. Following on from this, presumably all parents whose children were deemed to have had a negative audit finding will require a meeting with the audit team to determine clinical management. It is not clear if this has been thought through.
A central factor in all of this is a lack of understanding of paediatric mental illness and its treatment by those charged with governing and reviewing it. Mental health (and by extension mental distress) is not mental illness and does not require the same expertise.
Mental illness in children and teenagers demands parity with physical illness. It would be unthinkable that reviews and expert committees relating to paediatric medicine and surgery would be carried out without key involvement of paediatric expertise. Yet this is what has happened and continues to happen in paediatric psychiatry. Further, it is noteworthy that long outpatient lists of 18 months and more together with delayed access to both medical and surgical treatments following initial appointments are commonplace across the HSE and yet do not evoke the same blame being attributed to the service itself as is the case for Camhs. Within the HSE structures that exist the Camh services, of which there are 74 nationwide, are the equivalent of paediatric services nationwide for childhood physical illness. The model of providing services for moderate-severe mental illness at a local level was built on the simplistic assumption that local is better; this would be unacceptable as a rationale for a service framework relating to serious physical illnesses. As has been replicated in multiple international studies of patient outcome in medicine, optimal treatment outcomes are associated with timely access to medical expertise in well governed, centralised, high-volume departments with ready access to subspeciality expertise. Typically, these are centres which have clear referral criteria and treatment protocols. Such services must be resourced with appropriate budgets, training and IT infrastructure with a clear focus on maintaining high staff morale. Critically, the link between staff morale and optimal patient outcomes in high-performing units is driven by governance structures which actively encourage staff feedback and engagement to harness the human resources of expert clinicians in driving quality and effective change. This stands in dramatic contrast to the “learned helplessness” which is so sadly evident among clinicians and is an inevitable outcome of the HSE governance approach.
There is growing awareness that merely tinkering at the edges of the current HSE model of child and adolescent mental health service delivery will achieve nothing. Transformative change is required and this should include a centralised model of service delivery to ensure equity of access, service delivery and standards. Should anyone involved be interested, and as offered before, we remain happy to share our extensive research findings on child and adolescent mental illness and its treatment in Ireland together with our expertise and recommendations for service development. – Yours, etc,
FIONA McNICHOLAS,
Professor of Child Psychiatry
and Consultant Child
and Adolescent Psychiatrist;
BLÁNAID GAVIN,
Associate Professor and
Consultant Child
and Adolescent Psychiatrist;
ELIZABETH BARRETT,
Associate Professor and
Consultant in Child
and Adolescent Liaison
Psychiatry;
School of Medicine,
University College Dublin,
Belfield,
Dublin 4.