The lack of specialized children’s mental health resources is no surprise

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The Health Service Executive’s South Kerry (Camhs) Child and Young People’s Mental Health Service Maskey Report highlighted the state of specialist children’s mental health services in the country. The report has deservedly been in the headlines for the past week. It was ‘shocking’, said the Taoiseach, ‘beyond comprehension’, the HSE chief executive said.

Dr. Ian Kelleher is a Consultant Child and Adolescent Psychiatrist and Associate Professor at UCD School of Medicine

As a consultant child and adolescent psychiatrist reading the report, and as a parent, I was deflated, upset and angry. These children deserved a much higher level of care. But was I surprised by the results? Shocked? Not the least. And anyone who claims to have been surprised knows very little about Ireland’s crumbling mental health services or was just playing gallery.

Camhs is the specialist HSE service for children and young people with moderate to severe mental health problems, covering a distinct geographical area and led by a consultant child psychiatrist. Each Camhs team cares for hundreds of children and adolescents suffering from, for example, anorexia nervosa, depression, obsessive-compulsive disorder, attention deficit hyperactivity disorder and psychosis, as well as young people with suicidal thoughts and self-harm. This is very clearly a very stressful clinical environment.

Anyone who claims to have been surprised knows very little about the collapse of mental health services in Ireland or is just playing gallery

Given that our role is to treat some of the country’s most vulnerable children, you might expect Camhs teams to be adequately resourced. This is actually a myth that has been repeated ad nauseam over the past week by the government, including the Taoiseach in the Dáil, almost as if repeating it over and over again makes a reality.

Budget and resources

Here are the disturbing facts about Camhs resourcing:

– The World Health Organization recommends that 12% of the country’s overall annual health budget should be devoted to mental health, as is the case, for example, in the United Kingdom. In Ireland, however, only around 6% of the health budget is spent on mental health each year. Last year, in fact, when the mental health fallout of the Covid-19 pandemic on children and adolescents became chillingly clear, with an exponential increase in referrals to Camhs teams, only 5.1% of the Ireland’s health budget went to mental health. You read that right: mental health’s share of the overall health budget actually fell last year.

– There should be 100 specialist Camhs teams in Ireland. There are just 73. Within the individual teams, many are severely understaffed, with some working with only a quarter of the recommended level of staff. Clinicians are being stretched to try to keep up with urgent referrals and provide quality care.

– It goes without saying that each Camhs team needs a child psychiatrist specialist. But, as we learned from the South Kerry report, there are Camhs teams where this is not the case. Imagine a specialized cardiology department operating without a cardiologist. Or a specialized cancer service managed without an oncologist. This is the reality of what was happening in South Kerry and what is still happening in a number of Camhs specialist services across the country. That this resulted in major failures should surprise no one.

– Each of the nine Mental Health Service Areas in Ireland (known as ‘Community Healthcare Organisations’), in addition to their routine Camhs teams, should provide a specialist Camhs service for eating disorders. Only two of the nine domains are currently funded to provide such a service. Each of the nine areas should also be funded to provide a specialized Camhs psychosis service. None are.

– There should be at least 16 Camhs day hospitals – an intensified service by outpatient Camhs which allows for an increased level of specialist care for children who are more seriously ill and which may also avoid the need for hospitalization (which is available in only three counties in Ireland). The latest HSE report showed only two day hospitals in operation. In reality, most teams do not have access to a day hospital.

– Simple medical examinations such as blood tests and ECGs are not always available at Camhs. Instead, doctors should ask GPs or children’s hospitals to fill this gap and perform these basic tests for us. When it comes to more advanced investigations that should be routinely available to consultant child psychiatrists, such as neuroimaging, forget it.

Does it sound like Camhs has enough resources?

Shortage of psychiatrists

Of course, even if the government were to suddenly provide funding for all these shortages, which, following the Maskey report, it absolutely must, there is a national crisis in the recruitment of medical consultants. There is no pool of child and adolescent psychiatrists waiting to fill consultant positions here. One of the main contributors to this is the two-tier salary system for consultants, which results in senior doctors receiving completely different salaries depending on whether they had specialized training before or after 2013. It is therefore not no wonder so many consultants choose to go abroad rather than face the daily affront of being paid 30% less than their colleagues for doing the exact same job.

There is no pool of child and adolescent psychiatrists waiting to fill consultant positions here

Any government serious about solving the Camhs crisis and the consultant recruitment crisis would immediately address the disparity in consultant salaries. It would also increase funding for postgraduate medical training in psychiatry so that more physicians can complete their specialty training and thereby increase the pool of available specialists. The HSE itself estimates that it will need an additional 245 consultant psychiatrists by 2028. Where will these consultants come from?

The Taoiseach’s response to the South Kerry Camhs report was to order that there be a nationwide audit of Camhs. We don’t need an audit to know that teams aren’t delivering best practice care. Clinical excellence cannot be reconciled with gross underfunding and lack of resources. It’s just basic logic. What should be audited is the correspondence with and between members of the government about the lack of resources of the Camhs to see how “shocked” they really can be.

The South Kerry Camhs report revealed a scandal – but not just a scandal of an unsupervised junior doctor; it is a scandal of repeated political failure. These scandals will happen again and again – and children will be hurt – until the government seriously considers investing in specialized mental health care. The young people of our country deserve better.

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