Child mental health services failing and in need of radical overhaul – watchdog

The HSE’s Child and Adolescent Mental Health Services (CAMHS) “should be immediately regulated” by the Mental Health Commission (MHC), according to a major report from the independent watchdog.

CAMHS is a specialist mental health service providing assessment and treatment for young people experiencing moderate or severe mental illness up to the age of 18.

About 2% of children in Ireland fall into this category.

On Wednesday, the MHC said CAMHS is “a failing system that needs a radical overhaul”.

It identified a lack of effective corporate governance, gaps in risk management, and a “knee-jerk reaction to crisis” that was unsustainable.

The investigation found the “vast majority of teams were significantly below the recommended staffing levels”, with some operating below 50% of the target.

The HSE welcomed the review’s publication and said it is “genuinely sorry” to anyone who had a bad experience with CAMHS.

Chief operations officer Damien McCallion said the organisation is determined to make “substantial changes and improvements” in the mental health services provided to children and adolescents.

Speaking at the launch of the report, MHC inspector Dr Susan Finnerty said: “Staffing is deficient in almost in every area across Ireland.”

The commission said it cannot assure parents that all children in Ireland currently have access to safe and effective mental health services under CAMHS.

The inspector also highlighted obvious gaps in corporate and clinical governance.

“There has been poor risk identification and management, with serious risks unidentified and poor response when they are identified,” she said.

In terms of adherence to CAMHS guidelines, the review found care planning for some children was either “absent or of such poor quality as to be meaningless”.

Dr Finnerty said some services were not adhering to guidelines on care plans by not creating any or only filing “tokenistic” plans.

She said some plans only had “two or three words” in them.

She said staffing recruitment and retention could be improved through increased salaries and other incentives such as training and career progression.

However, she said “realistically” CAMHS would not be able to find all the staff it needs.

“That’s a fact, so we need to move on from that to see what the HSE can actually put in place.”

The publication of the independent report follows an interim review by the MHC in January which identified “serious concerns” in four out of five community health organisations (CHOs).

Dr Finnerty said independent and immediate regulation would ensure the State and the HSE “act swiftly to implement the governance and clinical reforms to help guarantee that all children have access to evidence-based and safe services”.

The review said it appears the rights of many children with mental illness in Ireland are being breached through long waiting lists, “lost” cases, lack of emergency services and lack of capacity for therapeutic interventions.

The review said a lack of governance in some areas is contributing to “inefficient and unsafe” CAMHS through a failure to manage risks and shortcomings in staffing and recruitment.

It said CAMHS is operating on an “outdated practice” of placing the onus of all clinical responsibility on consultant psychiatrists.

In terms of budget, it noted the HSE cannot provide an annual CAMHS budget but estimates a total spend of 137 million euro per year – or about 12% of the total mental health budget.

Within the past six years, 22.6 million euro of development funding has been directed towards youth mental health.

The MHC said there is still evidence of under-resourcing in CAMHS.

The independent review found deficits in risk management, noting that some teams “did not ‘bother’ to escalate risk anymore because there was no point”.

It added: “This resulted in a haphazard approach and under-documenting of risks and minimalist generalised actions recorded on the CHO risk register.”

On staffing, there were particular shortages in health and social care workers, occupational therapists, speech and language therapists, and nurse specialists.

“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.”

In some areas, acceptance of referrals to CAMHS was as low as 38%.

“Many young people and their families are frustrated, distressed and trying to cope with deteriorating mental health while waiting for lengthy periods on waiting lists for essential services.”

Some CAMHS facilities are located in old, unsuitable buildings which are poorly decorated and have a lack of appropriate clinical space.

Facilities were further criticised for a lack of soundproofing and inadequate storage of clinical files.

In relation to the 140 “lost” cases, Dr Finnerty said there had since been follow-up with all these individuals.

Additionally, the report found evidence that some teams were not monitoring antipsychotic medication and some children were taking medication without blood tests or physical observation.

MHC chairman Dr John Hillery said the review is the “most important report” the commission has ever done.

He said the report was “concerning” and there was a need for immediate regulation

“We can’t wait for the Mental Health Act,” he added.

Dr Finnerty said regulation would involve regular inspections and enforcement of actions to remedy deficits.

However, she said: “We have no indication at the moment that this imminent.”

Dr Finnerty also found a lack of digital infrastructure is “seriously hampering” CAMHS efficiency.

She said Ireland is among the worst in the world for IT infrastructure in youth mental health services.

“Our review of CAMHS has highlighted serious concerns about the provision of child-centred integrated mental healthcare in Ireland for children.

“The HSE is clinging to old models of service provision that do not adequately meet the needs of young people.”

The report calls on the HSE to urgently appoint a national director for mental health services and said the budget allocated to CAMHS should be increased.

The review also calls for a CAMHS-specific clinical director in each community health organisation.

It said all children and young people’s mental health services should be fully integrated so that children can move seamlessly between services in a timely manner.

It called for a clinical lead for mental health for asylum seekers, refugees and migrants while training in supporting LGBTI people should be rolled out to all CAMHS teams.

Asked if the HSE had given any guarantees on the recommendations, Dr Finnerty said: “No, we haven’t.”

MHC chief executive John Farrelly said he was “happy” the HSE had accepted the report and would consider it.

“But I will not be happy if we don’t get the strategy and we don’t get the plan and we don’t get powers.

“Because really, we have a chance here now to shift for the children of Ireland.”