Health Committee
Oral evidence: Children's and adolescent mental health and CAMHS, HC 342
Tuesday 10 June 2014
Ordered by the House of Commons to be published on 10 June 2014
Written evidence from witnesses:
– Cornwall Partnership Foundation Trust
– Birmingham Children’s Hospital NHS Foundation Trust
– Black Country Partnership NHS Foundation Trust
– British Psycological Society
Members present: : David Tredinnick (Chair); Rosie Cooper; Andrew George; Barbara Keeley; Grahame Morris; Andrew Percy; Mr Virendra Sharma; Valerie Vaz; Dr Sarah Wollaston
Questions 147 - 226
Witnesses: Dr Liz Myers, Consultant Child and Adolescent Psychiatrist/Clinical Director of Children's Services, CAMHS, Cornwall Partnership Foundation Trust; Dr Vinod Diwakar, Chief Medical Officer, Birmingham Children’s Hospital NHS FT; Dr Madhava Rao, Associate Clinical Director for CAMHS, Black Country Partnership NHS Foundation Trust gave evidence.
Q147 Chair: Before I ask the panel to introduce themselves this afternoon, I would like to pay tribute on behalf of the Health Committee to our Chairman, the right hon. Stephen Dorrell, who has stepped down. Stephen was an outstanding Chairman, and I speak for the whole Committee on this. He was a former Secretary of State, and I think we and the House were very fortunate to have someone of his experience in the Chair. We produced during his tenure 40 reports, which is a very considerable number, on a whole range of subjects, and he instituted some major changes to make sure that we held the Government to account more effectively—in particular, calling organisations like the Care Quality Commission and others before us to make sure that they were doing their jobs satisfactorily. So our thanks go to Stephen Dorrell and we wish him well in the future.
This afternoon we are considering children’s and adolescent mental health and services, and I would like the panel to introduce themselves, starting on my left and your right with Dr Liz Myers.
Dr Myers: Good afternoon. My name is Dr Liz Myers. I am a consultant child and adolescent psychiatrist and clinical director of children’s services in Cornwall.
Dr Diwakar: Good afternoon. I am Vinod Diwakar. I am a consultant paediatrician at Birmingham Children’s Hospital NHS Foundation Trust and I am a medical director of the trust. We run the child and adolescent mental health service for the whole of the city of Birmingham, which is around a quarter of a million children and young people.
Dr Rao: Good afternoon. I am Dr Madhava Rao. I am a consultant child and adolescent psychiatrist. I am also the associate clinical director for CAMHS for the Black Country Partnership, running mental health services for the Black Country and children’s services for Dudley.
Q148 Chair: I want to open by asking a general question. How has the demand for children’s and adolescent mental health services changed in your local area and what are the consequences of those changes, please?
Dr Myers: Over the last five or six years, since we have been collecting records, our referral rates have gone up approximately 20% year on year to the extent where we are currently commissioned to see around 2,000 referrals, but we have 4,000 a year. This has meant that we are necessarily having to prioritise those who have the most urgent and pressing need, and we have no capacity for earlier intervention and very little capacity for seeing those perhaps with the less life‑threatening or urgent risky presentations but for whom we could also do very useful pieces of work, such as those with neurodevelopmental disorders. It has also meant that the staff are feeling extremely run-ragged. There is increasing sickness, a lot of burn‑out and we absolutely recognise that there are increasing waits. It is not okay. We do not want that for our children and young people, but we have to just keep prioritising. So there are cancellations and times when at any one time we might be trying to manage situations where there is a need to have an in‑patient bed but there aren’t any. That takes us away from more of the front‑line work that could possibly be preventing admissions.
Dr Diwakar: The first thing to say is that in Birmingham the population is rising extremely fast. There is a baby boom in Birmingham, and it is expected that by 2025 there will be 14% more children. So demand is going to rise because of background population rise anyway. With regard to mental health, we are seeing an increased demand in terms of the number of referrals—over the last few years we have seen about a 14% rise—and it is not clear, in the absence of the prevalence dataset that we would hope would be conducted soon, how much of that is due to an underlying increase in mental health disorders itself, how much of it is due to an increasing acceptance of mental health and how much of it is due to underlying population rise. What we are seeing, though, is increased complexity. The average child has around six visits to our service. That is now rising, on average, to up to eight to nine visits to the service, so that might be one of the proxies one might use.
In terms of the impact on our service, the first thing to say is that although the demand is having an effect on staff, it has also driven innovation. Because of the need to see more and more children, there has been a greater need to redesign services so that we are seeing children in their home more and to integrate better with other services. All that said, however, there are issues that have arisen because commissioners have generally directed us to move away from supporting tier 2 services. We have had a strong history of working with general practice, schools and so on, and in general we have had to retract from that kind of work, which is rather against the spirit of early intervention earlier on in the care pathway.
Q149 Chair: Thank you. Dr Rao?
Dr Rao: In the Black Country we have seen over the last couple of years a 15% increase in the number of referrals. Dramatically, what has affected us more is the nature of the referrals that we are seeing. In 2012 we had to admit 16 patients in our patch. In 2013 we had to admit 35, so it has more than doubled in number. So far this year we have had to admit 9 children. It is very unclear as to why there is this level of complexity and this level of citizens in the presentations that we are seeing. Where it comes from is unclear. We do not have any prevalence data for a long time from this.
We run two services: a CAMHS service in Sandwell and a CAMHS service in Wolverhampton. The commissioning structures are different. In Wolverhampton we have a tier 3+ service and we are able to deliver some amount of care and prevent admissions. But in Sandwell we do not, so we are unable to provide any crisis intervention, even to A and E or divert any patients from A and E or the paediatric beds. So more and more of the children are staying for longer periods on paediatric wards, which is a completely inappropriate place for children with acute mental illness to stay. There are a small proportion of children who are so resource-intensive for us that it results in a huge chunk of perhaps the neurodevelopmental disorders, especially autism spectrum disorders and ADHD, falling way behind in their waiting times. We have changed the way we work to compensate for this. We have implemented what is called the CAPA—the Choice and Partnership Approach—to streamline the way the children move through the service. Even with that, we are only able to maintain the waiting times—I have it here—to around 16 weeks to choice and eight weeks to treatment. That is still not good enough. We would like that to fall even further, but we are unable to do so because a huge chunk of our work is taken up by the change in the nature of presentations that we are seeing.
Q150 Chair: Thank you very much for that overview. I have a couple of specific questions to ask before I hand over to colleagues. For you, Dr Diwakar, in Birmingham Children’s Hospital in your evidence you state that the Choice and Partnership Approach has reduced waiting times. How does this work? Do you think that waiting times for starting treatment are acceptable? I think you touched on this already.
Dr Diwakar: As I think the evidence says, when the Choice and Partnership Approach was implemented, around five years ago when I first became the medical director, there could be up to 200 to 300 children waiting 18 weeks or longer for their initial appointment, which was clearly unacceptable. By implementing the Choice and Partnership Approach, we have been able to bring down the waiting time for the choice approach to four weeks and then for the partnership appointment to 11 weeks. The choice meeting involves an initial meeting with one of the professional staff. Most of our professional staff have been trained in how to do these choice appointments. It essentially involves not only taking a history and discussing the problem with the family but also working out with them what they are hoping to achieve for their child or young person and how best to deliver that care. With some people it may mean that they talk through the problem and they are quite happy. For other people it may mean that they want some help from one of our professionals and then they come back to the partnership appointment.
I am a general paediatrician, so that means I make referrals into the CAMHS service—I am not a psychiatrist—and I certainly have personal experience over the 10 years that I have been a consultant of a huge improvement in the access to the CAMHS service. Now, when I refer patients, it is much better to be able to say, “Colleagues will see you within four weeks and then we will discuss appointments,” and so on.
Q151 Chair: There is better access, and presumably that is why we are getting more pressure.
Dr Diwakar: Quite. Of course, when you get better access you do drive up the pressure at the same time.
Q152 Chair: Let us leave it there for a moment. Dr Myers, turning to Cornwall for a moment, you said that the increases in more severe cases—fairly naturally—have put pressure on the other services and that the young people with neurodevelopmental disorders such as autism, ADHD and things like that are suffering. Is that right?
Dr Myers: Absolutely. That is because we do not have enough of everything to go round and, absolutely mirroring the trends here of increase in severity and acuity backed up by data from the Derriford hospital, whose casualty department we look after as well as the Treliske hospital, we are getting about double the amount of urgent referrals from A and E over the last couple of years. That is just one instance. We are also probably admitting about twice as many youngsters.
Q153 Chair: Is it because access has improved—the same thing as in Birmingham?
Dr Myers: Not at that high end; I don’t think so. Because they are presenting in crisis with very severe difficulties, there is an increase, probably, in problems at every sort of level, but one thing that is clearly impacting on us is the big increase of acute, very risky presentations.
Chair: Okay; let’s leave it there. Thanks. I think Andrew Percy wants to ask a question about Cornwall.
Q154 Andrew Percy: Thank you. I do apologise, but I am waiting to speak in the Chamber so I will have to leave not long after I have asked my question. It is nothing personal, I assure you.
On tier 4 in‑patient services, about which I think a number of colleagues have probably had issues in their postbag over the last year or so, in the evidence from the Black Country Partnership, to begin with, you state: “One of the most significant risks to the Trust is the availability and access to Tier 4 beds,” that the number of beds commissioned has not increased at the same rate as demand and that more patients are presenting with more complex needs. The Cornwall evidence states that there is a huge gap, and you provide an anecdote of a young lady who took it to mean that she needed to present with more serious issues in order to be admitted.
Could you perhaps give us some more of your thoughts with regard to what is really going on with tier 4 provision? I note that in the Cornish submission you also state: “The vast majority of Cornish admissions to Tier 4 units are unplanned,” which obviously means that this whole idea that we can plan in some way for something which is a very small, although increasing, number of individuals who could appear anywhere in the country is quite complex. Can you give us a bit more about what is actually going on behind what seems to be the increased requirement for tier 4 beds? Obviously we are aware that NHS England are undertaking their rapid review—which is so rapid it has been delayed—but could you give us a bit more on your understanding, your views, as to what is behind it and where we are headed in terms of tier 4 beds, whoever wishes to begin? We may as well start with Cornwall.
Dr Myers: I will put in the Cornish perspective, but I think it fits nationally as well. Certain parts of the country—for instance, Cornwall—do not have an in‑patient unit, so that is already a disadvantage, and now that we have gone to more regional‑based commissioning it is difficult to see how we can meet local need. For us, any admission is necessarily out of county and we do not, therefore, have very close links with the in‑patient units. That, again, makes it much more difficult to get youngsters out.
Q155 Andrew Percy: Has it always been the situation that you have not had tier 4 beds?
Dr Myers: Yes. We are currently trying to put in a bid to build a unit which we are hoping could take in people across the transition age gap, so we could manage 18 and 19‑year‑olds as well, but that is not going anywhere yet because we have to wait for NHS England. For us, the important thing is that we have the increase of severity and acuity, so that is increasing community risk, and there has not been a concomitant increase in the level of tier 3.5 or home treatment crisis teams. We do not have that in Cornwall.
The other issue for us is definitely that we think, from our point of view, Cornish youngsters are staying longer in these units because they are going a lot further and we cannot get them back, but also I think they are more unwell when they go because we do not access these beds that are so far away unless they are. A reasonable amount would be admitted under the Mental Health Act and they are very severely ill. I would say that we probably under‑admit compared with what we could call the level of need. I think there is a mixture of things, but with tier 4 beds there are clusters of the country that are reasonably well looked after but there are a few areas that are not. The south‑west is, I would say, very clearly one of them, because at the moment, if you think of the south‑west peninsula, we have Plymouth and Bristol, and Bristol is probably quicker to access from London than it is from Penzance. I think that there might be enough beds—I am not sure and I do not know—but they are certainly not in the right place.
Q156 Andrew Percy: I did quote Birmingham as well, so I wonder if we could have a response from Birmingham.
Dr Diwakar: We are a provider of a tier 4 service. I think Liz is right that across the country there is quite a lot of variation in provision and, therefore, in equity of access, and there are some issues, I think in our experience as well, upon the regulation of independent providers. For us I suspect we have enough beds per head of population. We have about 35 beds in our in‑patient unit and we are currently investing about £9 million in expanding that unit as a trust. Having said that, what happens in practice is that, first, there is a perverse incentive in terms of commissioning because it is based on occupied bed days, which holds back innovation to try and keep young people out of the in‑patient unit. Secondly, we are a net importer of patients from other regions. As a result, some completely ridiculous things happen. Recently, for example, we had a 15‑year‑old girl who came from Birmingham as a new presentation and she had to go to Newcastle for a bed, while at the same time we had someone from Newcastle being admitted to one of our beds. The lack of co‑ordination is completely outrageous.
The only other thing I would say is that there is increased complexity in the service. Over the last three years we have seen more children being admitted to hospital who have other diseases associated with them.
Q157 Andrew Percy: What is the driver for that? When we have looked at this and had the original panels, we know it is about general societal change, or whatever, and maybe some economic pressures, but what is your understanding of the key driver behind this increased amount and the increasing complexity that goes along with it?
Dr Diwakar: From my point of view there is an increased population that is going around, so we will see an increased demand just on the back of that. The lack of co‑ordination probably makes a difference. I am not really qualified to give an impression—I think my two colleagues who are psychiatrists could probably answer your question better—about what is driving it.
Dr Rao: To answer that question, first, perhaps, I am not so sure there is any one single reason that can account for all this. Even if you account for the decommissioning of tier 1 and tier 2 services, which are driven from the local authority, and even if you account for more social networking—the children who are more exposed to cyber-bullying where they have less protection from the other kinds of bullying that they are exposed to—I do not think it completely explains why this bump is there. In a sense, in one year, we doubled from 16 admissions in 2012 to 35. The team remained the same; we remained the same; the CAPA model remained the same, and we were working the same. In one year it doubled and that is a pattern that has been there. So, even if you account for all that, there still remains a large unknown factor as to what is driving this sudden increase in complexity.
The Black Country Partnership perspective is that this is a significant problem for us. I have brought up some examples. I will not tell you in detail, but we had to transport a 15‑year‑old boy all the way from Sandwell to Norfolk, where the parents finally found it impossible to visit him. He was just 15 and acutely ill—psychotic—and so they discharged him and brought him back to Birmingham, to Sandwell, even though he was not fully well. Now he has again fallen ill and is in Stafford. Another incident was where we had to complete the Mental Health Act papers—the medical assessment part 1 and part 2. We could not complete the Mental Health Act papers because there was no bed in the whole country. So we had to cobble together some kind of care between the police and the early intervention service to look after the child over the weekend till the situation got better.
As to my thoughts behind that, I can give you a small example. Three years back, before the division from the CCGs and NHS England was brought about, the CCGs—then the PCTs—were asked to top-slice some amount of their budget to form a regional fund to create beds for the region because the demand was small but very intense. The idea then from that team, which provided the beds working along with the PCTs, was to create a tier 3+ model. It has been shown everywhere that it can decrease the amount of admissions to these in‑patient beds. This was the same commissioning body which was proposing that we should work together with the PCTs to create a tier 3+ service, but, once this divide comes through from the CCG and NHS England, that same commissioning body will say that tier 3+ is a CCG problem and the CCG will say that a lack of beds is an NHS England problem.
The commissioning arrangements, I think, follow the law of unintended consequences; clearly people did not understand that this would happen. Both organisations are, in their sphere of influence, looking after their children quite well and efficiently, but they are not able to work together or form a link between these two to see that the children move along. For example, the early health cases are looked after by the local authority till a certain age, we look after tier 3 to a certain age, and then it becomes tier 4. It is the same child moving across, but the commissioning arrangements and the number of bodies which sit across that is so vast and there is no financial link between any of them. We meet, we can talk and say we should do this, but there is no link in the management of finances between any of these structures, which then puts the children at risk and our staff holding very dangerous children. I had to hold this child under the Mental Health Act—who was not under the Mental Health Act because there was no bed—at home.
Chair: We have quite a lot of questions in different sections so we are going to have to keep moving this afternoon.
Q158 Andrew George: I want to come back to Dr Myers. Obviously, I am a Cornish MP and I can confirm from my casework the patterns that you have described simply from a local MP’s perspective. If you are being commissioned for half the number that are actually presenting in terms of the severe cases coming before you, there are two issues which I think immediately arise. One is what further conversations you are having with your commissioners, particularly as you are talking about new commissioners as far as the CCG is concerned. The second is in relation to an initial comment of Dr Diwakar, where he said that the pressure is driving innovation. To what extent is this pressure driving innovation, particularly in relation to any conversations you might have with housing providers, primary care providers and with any family support that might be available in order that your services are not simply seen as a single silo of activity? That is for you, Dr Myers. In other words—
Dr Myers: Absolutely. First, on the commissioning issue we have very regular and in‑depth discussions with the commissioners. There has also very recently in Cornwall been an overview and scrutiny committee which held a select committee. So there is a lot of work going on as we speak, although I think the reality that we keep getting told is that there is no more money. With that in mind, with what we have, we are very actively trying to build up close links with the voluntary sector and the local authority. We are looking at starting to do some integration with the local authority. We are trying very hard. The challenge is that when you are on the back foot playing catch‑up all the time, even releasing staff to think about things is very difficult, let alone actually doing the stuff on the ground. We are trying to reach out and we are actually at this very moment having yet another rethink because we have tried the Choice and Partnership Approach, but we did not have enough people to do the partnership so it gets a bit difficult when you do not have enough staff. We are doing all of that and we have tried very much doing a 28‑day assessment. We do that, but then people cannot get treated. So we are actively trying to get out there.
As to Cornwall in particular, there are a lot of passionate people and a lot of people who really want to help out, but the difficulty is, for me personally, I think, around a lot of stark thinking. It is, “What do we think of our children and young people? Do we want to invest in them?” I am sad to say that I think that is not always given the priority it should be. The reality is that it needs a lot of tough thinking to re‑do it if you have no more money.
Q159 Dr Wollaston: It has been suggested to the Committee by a number of sources that we would be better to invest in tier 3+ services than in in‑patient beds. May I return to a point that Dr Rao was touching on, which was about the problems with the commissioning arrangements and why that does not happen? Dr Myers, is that your experience as well—this is all about the financial drivers being in the wrong place—and how could we address that?
Dr Myers: I think so. We know NHS England does the national commissioning for tier 4 beds and then locally the CCGs do the outpatients. I guess it is a question of, “What does tier 3.5 mean?” Is it in or out? It is actually sort of in a crisis model, a home treatment model. There is very encouraging evidence where it does work, but in order to do that you have to have a joined‑up system. That could be joined up—you do not have to be the same organisations—in that, if you have a local unit that you can relate to, you are then going to have a very successful bit of treatment.
Q160 Dr Wollaston: Do you think the answer is to have NHS England’s services moving from NHS England commissioning to local commissioning? Is it a problem that it is fragmented from the commissioning and if so, where should the commissioning sit, or should it be a pooled budget? Could the panel tell us what you would recommend? Do you have a joint view on that?
Dr Diwakar: My personal view is—and I think we would take the view—that there should be more collaborative commissioning between NHS England and CCGs. I am a chair of one of the clinical reference groups for paediatric medicine, and one of the things that have held us back has been a difficulty in engaging with CCGs. The new system of having NHS England and then CCGs seems to have created more division in commissioning rather than joint collaborative commissioning. So I think that approach would certainly work for us.
We also have a tier 3.5 service. I think one of the reasons complexity has gone up in in-patients is because tier 3.5 are taking the less severe patients; I have had experience of that with patients waiting in hospital for an assessment who have not come into hospital and have gone home.
The third thing is that our tier 4 service provides a regional gateway assessment service. About 20% to 30% of our referrals for tier 3.5 are not taken forward into tier 3. So again that will drive it. Like everyone else, I think we do have problems with our local CCGs about who funds this service. My personal view would be that if a way could be found to promote collaborative commissioning that would be very much better.
Q161 Dr Wollaston: So you think collaborative commissioning rather than making it all sit in one or the other?
Dr Diwakar: Personally, I think there are advantages because there is no doubt that tier 4 is a specialist service, and when we have a problem with inequity across the country, a degree of national strategy which aims to put the right resources in the right place is going to be essential. My concern about breaking up and devolving all of CAMHS into local commissioning may be that that sort of system might go wrong. At least for a period in the next few years, until we have tier 4 CAMHS sorted out better, we should have a degree of national co‑ordination.
Q162 Dr Wollaston: Would Dr Rao and Dr Myers agree with that approach?
Dr Rao: Yes. I have one additional thought. In Birmingham we have, as Vin says, the gateway assessment, and that is very useful if we are very worried about a particular patient. I can then ask for a gateway assessment; another tier 4 clinician would come and look at the patient and then suggest, “Perhaps we can do this or that. Maybe becoming an in‑patient is not the correct approach now, and maybe there is much more social and family help that can be delivered.” Those are solutions that we take on. Dr Cullen runs our unit, and she has consistently shown that not all the patients sent to gateway are admitted and they are diverted back to tier 3 for us to get additional help. The same gateway is not there in other parts of the country; there is no such gateway. So that can sometimes result in inappropriate admissions into tier 4 when the appropriate care would have been perhaps social care, increased support for the family, or perhaps in some other more appropriate unit. But in the absence of the gateway in other parts of the country and since it is a national model and the children can move around, sometimes it is the children with perhaps social issues or other difficulties, not mental illness, who can be sitting in one of the west midlands wards and they find it difficult to discharge back.
Q163 Dr Wollaston: That was the next question I was going to ask. Is there a problem with discharging children from in‑patient units because there are not the tier 3 services to refer them to?
Dr Rao: Yes.
Dr Diwakar: Yes. As Dr Rao has said, my colleague Linda Cullen, who is the clinical lead of our service, has recently audited some data and shown that those regions or areas that do not have tier 3.5 or tier 3+ have approximately double the length of stay for their children as those areas that do.
Dr Wollaston: Thank you.
Dr Rao: Going back to the collaborative commissioning, I agree that, if the whole of the money sits with NHS England or the whole of the money sits with the CCGs, we will be just going back one or the other way. Some amount of regional flexibility will be better if NHS England can work with the local CCGs.
Q164 Rosie Cooper: Just listening to the discussion today, I am sure that problems about who funds which bit of the service will not be welcome news—or welcome listening—if you are a doctor, a parent or a child who desperately needs urgent help. Tanya Byron gave us some evidence early on and spoke about children in crisis from London ending up north as beds and services were not available here in London, with those pressures. It is almost like a very sad case of “pass the parcel” and it is tragic in its consequences.
We hear about the levels of self‑harm and crisis presentations, as I have outlined, increasing. It is not necessarily just about putting those services into beds. What services do you think are needed, including out of hours, to cope with it? In my area CAMHS are struggling; I don’t really know where they are. Parents and families are in crisis, and then we go right up the tiers. It is very difficult. What do we need? What does best practice look like? How does it compare with the areas you know? None of you are in the north—I represent west Lancashire and above—but I am sure there must be similarities. It is a long and complex question, but how do you deal with the crisis that you have? What does best practice look like? How do you get us there?
Dr Diwakar: The first thing to say is that, in general, across all the tiers we also have children who present in crisis to the main children’s hospital. Yesterday I was in our main hospital operations centre and there were seven children waiting on various wards for gateway assessments, waiting for a bed in tier 4 or waiting for social support. When you present in crisis there does need to be 24/7 access to an emergency response team, which we again have. It has only gone in in the last year. That again for me, as a paediatrician, has been a fantastic addition to the service because one can now react quickly to children and young people, whereas, before we had that service, a child would be admitted and I, as a paediatrician, would go and see them the next day. I do not have a lot of mental health training and would have to say, “I am sorry, you have to wait for the psychiatrist,” and they would then come. Because they only came twice a week, this wasted an in‑patient bed and also proved to be very frustrating for the young person, who would often try and take their own discharge. In my view, the response, in terms of an emergency response team that can go to local hospitals, is going to be absolutely essential.
In terms of what Dr Rao said, there is a great deal of evidence that tier 3.5 does seem to be of benefit. From my point of view, I would say to you, as a Committee, there ought to be more investment in tier group 3.5. I think gateway assessments make a difference. Families need to know what they have a right to expect, who is responsible for delivering it and what they can do if they don’t get it. What I am not seeing at a national level for tier 4 is somebody who says, “It is my responsibility to get your young person admitted to the nearest tier 4 bed that can meet your needs.” I think a degree of national co‑ordination of that with a face that people can talk to has a great deal of benefit. This business where I have to go and say repeatedly, “I am terribly sorry you are still waiting for a tier 4 bed, a tier 4 bed, a tier 4 bed” just does not work, and I have seen several complaints.
Q165 Rosie Cooper: Does that still not have an element of “pass the parcel” in it?
Dr Diwakar: Only, I think, if there is no central co‑ordination. If I take the example of paediatric intensive care, which is an area I know rather better, again you do get periods where the service is overwhelmed and children have to be transported across the country. But certainly what happens in the west midlands is that there is a single number that you can ring if you are a paediatrician wanting an intensive care bed. That is our retrieval service. They have an overview of where all the in‑patient intensive care beds are across the region and indeed all the main regions across the country. They are able to teleconference in the paediatrician making the referral and the paediatricians who need to support that child, and make a joint clinical agreement about where it would be most appropriate for that child to go. So from the family’s point of view you can say, “We have spoken to what is called the KIDS service—the intensive decision support and retrieval service. They are responsible. They have found you a bed. We are going to send an ambulance and this is where you are going to go.” If a family has to follow an ambulance, they will give them a sat‑nav so they can find their way to the hospital and provide them with a pack of drinks. What we or my colleagues have developed there is a service that is extremely responsive to the needs of children who are critically ill. I think we should aim to get the tier 4 service into exactly the same state, where there is central co‑ordination either at a regional or national level which allows families to know that there is a single person or team who is responsible for finding the most appropriate placement and you can give them a name so that they have an identity.
Q166 Rosie Cooper: Forgive me, but in places like west Lancs, where in Skelmersdale, for example, there is low car ownership and no buses, all that is pie in the sky. These people are never ever going to get to their relatives who are ill. This is a national health service. What on earth is going on?
Chair: We will let Dr Myers answer. We are up against it and have a lot to cover this afternoon.
Dr Myers: I will try and keep it brief. I absolutely agree. Cornwall has exactly the same issue. I think that tier 3.5 is needed. It is not the full answer. There need to be local units, a local buy‑in to all of this, but not only that. The difficult decision is whether we are going to prioritise children and young people or not. That will mean looking, as health communities, at where we put our money.
Q167 Dr Wollaston: Very briefly to Dr Myers, in Devon and Cornwall the police on 31 occasions in the last full year for which there was data available were actually using police cells under section 136 to detain the sickest children in the region. How are we going to move away from that? Do you feel confident that progress is going to be made with the Crisis Care Concordat or what do you feel?
Dr Myers: That is very timely. I am going to a meeting about that next week. I would love to say yes, I feel confident. I still don’t. Unfortunately, we still live in a very adult‑centric world. My view is that children and young people should be prioritised for resources. I think things just overtake that. I would love to say yes, but I am working on it.
Q168 Dr Wollaston: Do you think the answer is in‑patient or tier 3+?
Dr Myers: Both. I think children and young people have a right to the same level and degree of care, if not more so, because they are our future, because we can intervene earlier and because there is a lot more we can do for them than adults. The problem is that everybody is playing catch‑up. CAMHS is always playing catch‑up.
Chair: Thank you.
Q169 Grahame M. Morris: I have a fairly brief question to Dr Diwakar in Birmingham. It is on the issue of eating disorders and it is an issue that I have received representations on in my region, which is the north‑east, as you can probably tell from my accent. From discussions with other colleagues, with your contemporaries, all three panel members in written evidence have raised eating disorders as a specific challenge facing the service. Birmingham mentions that there was a proposal to develop an outpatient service and that did not happen because the commissioners were not prepared to fund that. Is it possible to draw any conclusions across the board geographically—it certainly seems to be a problem in my region—and what is the best way forward to tackle it?
Dr Diwakar: I can expand a little about our own service and then let my colleagues perhaps answer the question. Briefly, first, we know from evidence that young people with eating disorders sometimes do less well in an in‑patient setting. We believe, again from evidence, that a family‑centric systemic therapy approach which engages the family and the other resources around them is a better approach. That will decrease the risk of relapse in families and allow us then to discharge those families from tier 4 back into tier 3. As you say, within tier 4 there is this perverse incentive that funding is based on occupied bed days, which then acts as a disincentive to developing outpatient services, and certainly I suspect that is a problem everywhere in the country.
I want to pick up one thing. It is a scandal and an outrage that police cells are used for section 136 patients. Again, I think this is part of this whole tier 4 equity thing that there have to be proper tier 4 beds for emergency patients.
Dr Rao: In the Black Country we do have an eating disorder service but that sits with the adult services and we have a working relationship; we try our best and they do help us in providing extra support for the children. It is a strange situation, as eating disorders largely, by definition, begin in early childhood rather than adulthood, that we do not have an eating disorder service. We use our adult eating disorder service to help the children. I do not think the solution is just tier 4 beds. If you create more beds, there will simply be more children perhaps inappropriately there. It needs perhaps a plan or a basic template for the commissioners on how to build a service, for example, with the tier 3+, with links and collaboration with tier 4.
Perhaps I should mention, as it was not mentioned before, that the early help services, at least in my area, have largely been downgraded. We have had a counselling service which was operating from 5 to 18 and in the last round of changes—that was commissioned by tier 2, that is a local authority commissioning—
Q170 Grahame M. Morris: Was that delivered in the schools?
Dr Rao: That was delivered at schools. That was an excellent service and still is, but because of how it was restructured they simply turned round and said, “We will not see now any children below the age of 10.” So all the counselling services for all those below that age just disappeared and they made it much more difficult for the GPs to access it because they said, “This is a CAF‑only process”—the Common Assessment Framework process. Without a Common Assessment Framework being in, they cannot get a tier 2 service, but they can get a tier 3 or tier 4 service with a simple letter. It is a very strange system that we seem to have developed. To get more basic, much needed help, you need to jump through many complicated hoops, but to get to our tier 3 specialist or tier 4 unit it is straightforward. It should be the other way round.
Q171 Andrew George: Can I raise the issue of autistic spectrum disorders, which of course are not in themselves mental health problems, as you point out in your submissions—at least, Dr Myers and Dr Rao? There are nevertheless both skills to treat the disorders within your services and also occasions when those with autistic spectrum disorders do have co‑morbid mental health problems as well. You indicate that this is presenting significant challenges to your services and it seems that in both locations there appears not to be any proper service to diagnose and support those in that spectrum. Could both of you say a little more about how you see that particular challenge going forward and what you think is required to really give that particular cohort of people the support that they clearly deserve?
Dr Myers: You are absolutely right that there is a group of young people who are at increased risk of mental health problems and meet a lot of challenges along the way. If we take it from the diagnostic part onwards, in Cornwall we now have some extra money to provide a diagnostic pathway but it does not provide anything else. Because of a combination of changes in education, withdrawal of some of the funding and the support there—
Andrew George: Exactly, yes.
Dr Myers: —which is driving things, as well as all the challenges on tier 3 and tier 2 CAMHS, what we are seeing is that these young people are certainly not getting early intervention; there is not a lot of specific support. In Cornwall we do have a really great autism support team, but, again, they have been pulled right back. It is really difficult to know what the way forward is. It has to be integrating services and collaborating as far as possible, but it is such a holistic issue because it really is from the early years onwards that these young people need the support.
Q172 Andrew George: I want to ask you specifically on that, “the right‑hand left‑hand” issue, what your service is doing in terms of having a pathway to diagnosis, but with the withdrawal of support, so it appears, from the education service for special needs education within mainstream education itself. Presumably you must be having conversations with schools, or at least the education service, about the fact that accessing support through SEN in mainstream schools seems to be significantly difficult now.
Dr Myers: I think that is right. We certainly try—with the emotional wellbeing and mental health boards and things like that—but education now can be quite disparate, where you have academies, free schools and different areas of provision, and they all have choices over how they spend their money. What seems to have happened—and it certainly is at risk of continuing to happen—is that health, as the universal service for everybody, ends up catching all of those. Part of our increase in referrals has been young people who really should have been dealt with at school and the problems should never have got to the stage they got to. But they are not getting picked up and they are not getting the support. I am not quite sure how we can change that, given the way that education is right now. It can only be done with a lot of very clear and quite directive instructions around collaborating together.
Dr Rao: In Sandwell we have modelled an excellent service for autism; we have a working partnership with education and we have a working partnership with primary care, speech and language, and we separately and jointly assess the child; we jointly provide a diagnosis. The model is excellent. It was even declared a beacon site some years back. What has happened is that it is nobody’s child because it sits between primary care, education and health. It is not on the agenda for the CCGs, it is not on the agenda for the diagnostic pathway and it is not on the agenda of anybody. The waiting time is scandalous, and I keep saying we should walk away from it. But if we walk away, if I walk away, there is nobody there. It is a 24‑month waiting time when I refer a child for what is called a multi‑agency assessment. It is not just CAMHS or health; it is three agencies in one. They have to wait about 24 months for a standard assessment, which is not a system. We cannot continue to operate like this. But since it is nobody’s child, we continue to hold up that service because if we walk away there is nothing there. That is just the diagnostic service. Post-diagnosis we have excellent support from the voluntary sector, Autism West Midlands, who support our children to a great extent, and in tier 3 any co‑morbid severe mental illness we still treat and help. So post‑diagnosis is not our difficulty. The diagnosis pathway, while the framework is excellent and completely evidence based, is falling down because of waiting times because nobody wants to own up to it.
Q173 Dr Wollaston: It is obviously a nationwide issue. Certainly in Torbay alone—in my area—there are 64 children on the waiting list, and there is a very long list as well across Devon, with people being overwhelmed. What do you feel is the solution? What do you feel should happen? Is it entirely a resourcing issue?
Dr Rao: I do not think it is a resourcing issue. It should be owned by somebody. If three people own it, what then happens is that everything takes so long. Everybody is working as hard as they can, but if one person owns it—it does not matter which agency—it will help.
Q174 Grahame M. Morris: Following on from the earlier answer that Dr Rao gave about the erosion of early intervention services, I think he gave some examples about the Black Country Partnership—the NSPCC, “Bump Start” and other voluntary sector services—particularly as the services for victims of sexual abuse had been withdrawn because of a lack of funding. What is the solution? Is this as a consequence of austerity and cuts to local government that is not funding the charities and the voluntary sector? Is it local commissioners who are not seeing the value of this service? I am looking for some solutions or suggestions really, Dr Rao.
Dr Rao: Yes, I agree with you. We have lost services after this age of austerity, as you may call it, and they were delivering excellent services, especially the “Bump Start” in Wolverhampton. There was also what is called the TAMHs service; there is the help for schools—the counselling services for schools—which was again withdrawn. They did pilot it for one year and it had excellent results, and they then withdrew it. I am not so sure why all the help across children’s mental health, in terms of whether you are in tier 1 or tier 2, sits across so many agencies. Why does it sit across so many people? It is the same child. Either they are growing older or they are developing different kinds of problems, but we are—
Q175 Grahame M. Morris: Forgive me for interrupting. What was the consequence particularly of withdrawing the funding for that service to children in schools? Has that manifested itself as more tier 4 admissions, or is it too early to tell?
Dr Rao: No, I do not think we can draw that correlation or conclusion very early. What it might have meant is that they would refer more children to the CAMHS service. We have an open reference system. We accept referrals from nearly all the agencies. We accept referrals directly from schools also. They refer directly to us.
Q176 Grahame M. Morris: You said it was 100% up in your opening statement.
Dr Rao: Yes, so maybe that is the reason, and we have tried to change and work differently. We have two primary mental health workers who go into schools and deliver training sessions, but we still cannot contain the increase in referral rates.
Q177 Grahame M. Morris: I will be brief. In Birmingham there are primary mental health workers, are there not? There is a primary mental health worker service and that has had some success. I wonder if you could tell us a little bit about that.
Dr Diwakar: The service itself has had some success. I would concur with my colleagues on either side of me that there have not been enough primary mental health workers per head of population, and we have seen a retraction from early intervention services in Birmingham, as elsewhere. I do not think I need to tell anyone about the issues to do with children’s services in Birmingham and the finances of the local authority, but what I think we have seen is an increasing separation between the two agencies. In the local authority we know that there have been both cutbacks to the local authority grant into tier 3 but also an increased withdrawal of services into tier 2. With regard to what the health commissioners are doing, the guidance to us is not to get involved in trying to back‑fill in primary care training or in health visitor training, or whatever it is, but actually to pull in our boundaries and focus on pure tier 3 work. The question I have asked as medical director repeatedly is, “Who is owning that risk?”
Q178 Chair: So it is “ownership” again, the same language as Dr Rao.
Dr Diwakar: Yes, exactly. There is no one looking across the system and saying, “If these two parts separate, who is looking after the children in the gap?” Presumably, if you have made a referral and your tier 3 service refuses it, that means—
Chair: Just before I continue, is that all right, Grahame?
Grahame M. Morris: Yes.
Q179 Chair: Just before Sarah comes in, from what you are saying so far, ownership is a key issue and the misapplication of resources is an issue, with ambulances buzzing to the wrong parts of the country where parents cannot follow. A general misallocation of resources comes through to me as one of the issues. Is that right?
Dr Myers: Yes.
Q180 Chair: It is a misallocation of resources and the resources are not actually going in the right direction.
Dr Rao: They need to be more linked up. The resources need to be linked up from the CCGs and NHS England to provide a seamless care from tier 3, 3+ to 4.
Chair: Seamless care. Let us leave it there.
Q181 Dr Wollaston: Going to the other end, from tier 4 right back to tier 1 and the role of the voluntary sector, in my area Home‑Start is a wonderful voluntary service provided—supporting families. They are in some areas falling over. Their grants are drying up, and in the city part, in Plymouth, the service is being decimated. How much do you feel there is an evidence base to support that they help stop children moving through the system and pick them up and provide decent preventative work? Do you think this is good value for money, in other words?
Dr Myers: That has probably been a question that has vexed a few minds for quite a while, dating back to Sure Start days and things like that. My view would be that there has to be value in supporting people at a very early stage, whether that means they either get help earlier so that they get better sooner or that they just have a better journey. Sometimes it is not all about saving money; it is about giving people the support and care that they need at the right time. With things like Home‑Start and those sorts of tier 1 services, we know that we can increase resilience and do a lot of attachment-focused work and things like that, which can help relational aspects early on which will pay dividends later on, not just for mental health but for youngsters’ physical health as well. It is not going to stop everything happening. There are always going to be young people who need services, but I think there is so much evidence now about needing to intervene early. As to, “Is a specific model the way?” I do not know that it is quite as straightforward as that.
Q182 Dr Wollaston: Do you think they should have access to funding through health so that it is a single pot and there is a single overview, as you were saying, about ownership of the whole system?
Dr Myers: I think there could be something in that. If we really had a truly integrated budget for children, young people and families—because it has to start with parents and supporting parents, and in the antenatal period through—there could be something there around using all resources together, and then you do not have to argue about whose pot it comes from and you do not have to push something over the fence to someone else. Science tells us so much about early intervention from the point of view of growing brains and relationships and things, but it is broader than that. It is about the whole community.
Q183 Chair: Did you want to come in on that, Dr Rao?
Dr Rao: I think the voluntary sector and tier 1 and tier 2 have a significant role to play. It is a way to pick up parental mental illness, a way to pick up on strategies like parenting programmes. Parental mental illness needs to be emphasised again; the earlier it is picked up, the better. We usually end up picking it up by the time the child comes to tier 3. That means they have had to experience quite a lot of difficult situations at home before they come to us. If that was picked up earlier, then maybe help can be delivered at an earlier stage. Whether there should be an integrated budget there, I don’t know. I do not have an opinion on that particular issue.
Chair: Thank you very much.
Q184 Andrew George: We are beyond our witching hour, which is probably a very inappropriate statement, but, with that in mind, I will roll a number of questions together. It seems to me from what you are saying that you have referred—I think certainly Dr Diwakar—to clear national expectations, national standards, with regard to commissioning. I know that, Dr Myers, you were talking about the development of national guidance with regard to commissioning, but I am not quite sure at the end of all this. Are you all saying that in fact what we require in this sector is national commissioning and that local commissioning is failing, or is it that we need clearer national guidance or standards? The impression that we are getting—certainly from the evidence that we have received—is that it is very patchy and very different; there are some strong and weak areas with regard to where the resources lie.
Dr Myers: Clearly that is a very political thing to try and answer, but for me what it says is, “Look, we have got some really good documents already existing around the sorts of things that should be commissioned for CAMHS.” The Royal College has a very good document. What we also have, though, is the localised commissioning groups who are looking at needing to make savings and do things like that, so they are having to make the call. For me, it would be helpful if there was absolute national guidance on at least a bare minimum that you are meant to provide because, locally, commissioners can make a choice about what to invest in or not to invest in. So, for me, there needs to be an absolute bottom line, “You must get this level.”
Andrew George: That is helpful.
Dr Diwakar: In specialised commissioning, there are service specifications that provide exactly that sort of guide to the local area teams as to what to commission. I do not see the same for CCG commissioning, where it very much depends upon the CCG’s own professional knowledge of the sorts of services available. I think one of the solutions is to provide that sort of guidance, so not to break up the service. I do not think CCGs are failing us and there are many very good examples, but I do not think they have enough guidance. That should come, I think, in the same way as the clinical reference groups are NHS advisers, rather than it being Royal College guidance. Royal College guidance always tends to have that sense of, “People want resources for their own needs,” if you like. It should come from the NHS and there should be discussion then about how best to allocate resources. Resources per head of population should be tied into acuity, complexity and dependencies. There is quite wide variation at the moment.
Dr Rao: I will keep it short. If the nationalised commissioning for tier 4 carries on without any change, in my world it will fail. If I have to not hold a child where there is no bed and if I have to transport a child to Norfolk, this is not working. There needs to be some kind of link‑up or a change in how this is structured.
Q185 Chair: Thank you. I have one more question. Then I am going to ask each of you if there is anything you want to say that has not been covered in the questions. But if you do not have anything extra to say, you do not need to say anything because we have another session to come on straight afterwards. What services do children’s and adolescent mental health services provide to looked‑after children? Is this support being affected by recent pressures?
Dr Rao: Can you repeat the question, Chair?
Chair: What services do CAMHS provide to looked‑after children? Is this support being affected by recent pressures, please?
Dr Diwakar: In the past there was a commissioned service where social workers and CAMHS workers were integrated together. What has happened more lately is those have been separated and so the looked‑after children are now looked after by a social‑work based Therapeutic Emotional Support Service, I think they are called, and they only reach CAMHS when there is a placement breakdown or some sort of mental illness arises. My sense about this is that it would be much better for these children to be spotted early and to have interventions early from CAMHS professionals rather than separating them and waiting for a crisis to happen.
Q186 Chair: Thank you. Is there anything else you want to say?
Dr Myers: Could I make a comment on that? There is variation across the country. In Cornwall the local authority has a psychology service and I also work in it a day a week. Looked‑after children have access to CAMHS but they have to meet the thresholds. What is missing is targeted interventions and also specifically for care leavers and those in transition.
Dr Rao: I agree. It is different in Sandwell. They were providing a psychology service and there was a full looked‑after children’s team that the local authority had funded. They decommissioned the whole psychology service and transferred all the care to CAMHS. So they now have to meet the CAMHS threshold to have any help from us. But for them we have a different way of working. We cannot simply turn round to these children who we are seeing, who are quite in need, and say, “You have to meet this threshold,” so we have changed the way we work. We have turned into a part-consultation mode in which a huge chunk of the clinical time is given to consultation with the social workers regarding the looked‑after children and directing appropriate help when required.
Chair: Thank you, all three doctors, for your time. It has been very helpful.
Witnesses: Dr Jenny Taylor, British Psychological Society, Dr Amanda Jones, Professional Lead & Consultant Perinatal Psychotherapist, Perinatal Parent Infant Mental Health Service, North East London NHS Foundation Trust, Dr Sebastian Kraemer, Consultant Child and Adolescent Psychiatrist, Whittington Hospital, gave evidence.
Q187 Chair: Good afternoon and welcome to the Health Committee. Would you be kind enough to introduce yourselves? Would you start first, please, Dr Taylor?
Dr Taylor: Hello. My name is Dr Jenny Taylor. I am a consultant clinical psychologist and a lead psychologist for a CAMHS service in an NHS trust, but I am here representing the British Psychological Society, the professional body for clinical psychologists, but also educational psychologists, counselling psychologists and other practitioner psychologists who work with children and young people.
Dr Jones: Hello. I am Dr Amanda Jones. I am the professional lead and consultant perinatal psychotherapist from North East London NHS Foundation Trust, which has a specialist perinatal parent/infant mental health service, which I work for.
Dr Kraemer: I am Sebastian Kraemer, chartered psychiatrist at the Whittington hospital, paediatric department.
Q188 Chair: Thank you. I will start by asking this question. What, in the view of your members, is the state of children’s and adolescent mental health services—CAMHS? We have noted that 70% of the people you surveyed raised concern around provision of services in the area of deliberate self‑harm and suicide prevention. What, in your view, should be the priority areas for improvements in these services?
Dr Taylor: As you say, our members’ views—who responded from working within NHS trusts—fitted with the responses we heard in the earlier session about generally increased pressure. There is not necessarily great clarity about where that is coming from, but there is a clear experience on the ground of increased pressure. In terms of what we do about it, one of the things I was struck by when we were listening earlier to the evidence given is that we are talking a lot about access to services, but we also need to make sure that the services we are delivering are effective and making a difference. So there is an element of access and funding that everybody seems to be fairly clear is what we are experiencing at the moment, but I think what we have not spoken about as much is ensuring that the interventions that we offer when children and young people do come to our services make a difference to whether or not they return and deliberately self‑harm or whether they actually attempt suicide.
Q189 Chair: So that is results-based.
Dr Taylor: To some extent, but also using the information we already have. We have, for example, a lot of NICE guidance about children’s and adolescent mental health services. One of our colleagues who spoke earlier talked about the need for commissioning groups to ensure that there were certain provisions. That would be a starting point, making sure that CAMH services are providing, at the least, what the NICE guidance recommends needs to be provided, as opposed to emphasising needs for numbers of staff, for example, or particular disciplines. But, yes, I think it is about looking at whether or not we are making a difference to those children and young people who are coming into our services and presenting with deliberate self‑harm: is that continuing? It is not just about how quickly we are seeing them but whether we are making a difference to that behaviour. At the moment many services feel that there is a far greater requirement for them to report on targets, such as waiting lists or the number of children being seen, rather than a great interest in whether or not they are making a difference to those children and young people.
Dr Kraemer: While we are waiting for the evidence, there are things we know we can do effectively, usefully and helpfully with deliberate self‑harm. In a crisis you can more easily get hold of young people’s families. Separated parents will come from various parts of the country for a consultation on a paediatric ward where a girl, typically 15, has just taken an overdose and been admitted. Although this big study called SHIFT—“Self‑harm intervention, family therapy”—is not complete, I hope and expect it will show that family intervention at the crisis stage is vital because there are a lot of things that can be said in such a crisis that cannot be said in the cold light of day, even two days later when the young person says, “I am sorry I did that. It did not mean anything,” and it has all been put under the carpet. So there are things one can do and there are things we have to do.
Q190 Chair: Would you like to add to that, Dr Jones?
Dr Jones: I am not placed to speak about CAMHS in this regard but more about perinatal parent infant mental health, which I suppose is the earliest possible intervention that can be made in the hope that one might protect a baby from becoming a young toddler and a young child who will need CAMH services later on. I have been asked to come to the Committee to call attention to the disparity of services that there are across the UK to provide an intervention to a woman, and obviously her partner, during pregnancy and in the early post‑natal period. In the service that I work for, we see over 1,200, often, referrals a year of really quite catastrophic situations. So one only has to imagine that the babies of those mothers and fathers are going to go on possibly to have considerable difficulties in the CAMHS interventions later on.
Q191 Barbara Keeley: I was interested in what Dr Jones was saying there. One of the concerns I have in my own constituency in my own local authority area is proposed cutbacks to Sure Start. It seems that Sure Start, to me, has been able to bring together services which do not normally cross boundaries very well. There is reference, in terms of your own work, to the difficulty there is if there are adult practitioners or professionals and children, and it is very difficult to work across those boundaries for the mother and the baby or child. Our worries, if we cut back on Sure Start services, are about the denial of local services to women who are depressed and have mental health problems post-birth. Is that a concern you have too? Is that something we should be concerned about?
Dr Jones: Yes, I think so. In our area, which is for very large north‑east London boroughs, we have some absolutely excellent children’s centre services which provide community‑based support, parenting groups and classes for mothers and babies, which I think are lifelines to many parents. But the really emotionally ill mothers often are not well enough to access, at the early stage, community‑based resources such as that. In a sense, they need to have specialist mental health input to get them to a position where that can then help their ongoing recovery. Certainly I have heard on the ground, in terms of our local area, that there have been severe worries about resource cuts for some of those very good children’s centres. What is more of a worry to me is to think that there are 50% of NHS trusts across the country who do not even have a perinatal specialist consultant psychiatrist, let alone a team like ours, to even think about these needs. That figure comes from a report done by the NSPCC a little while ago.
Q192 Dr Wollaston: I have a question for Dr Taylor. In your submission you state that many evidence‑based treatments recommended by NICE are not being offered by services, and indeed you have touched on that in your last answer. You mentioned that the progress on this has been very slow and there has been a great deal of resistance. Could you clarify where that resistance is coming from and what can be done to tackle it?
Dr Taylor: One of the difficulties with recommended interventions from outside coming in—but in the case of NICE, by saying “outside”, we are talking about an independent body, not something that is attached to one professional body or another—is that the guidance may recommend particular therapeutic modalities. At the moment the way many CAMH services are staffed is that the staffing involves people who are trained in one particular modality. If someone is trained in one particular modality, it is not particularly appealing if evidence comes out suggesting that that particular modality is not the most useful modality for a particular intervention. So I think anyone working within CAMHS can potentially be cautious about evidence coming out that suggests a particular intervention is not the intervention type they are trained in. Our current system of employing lots of single‑modality therapy staff sometimes makes it more difficult to move forward as the evidence changes.
Q193 Dr Wollaston: That is extraordinary. If you had it with surgery and a surgeon was carrying on doing a particular technique because that happened to be what they were trained in, we would find that outrageous.
Dr Taylor: It is a good parallel. As practitioner psychologists we are not trained in a particular modality. The assumption is that you change what you do as the practice changes, but as well as people like psychologists and psychiatrists who expect to move as the evidence changes, we do also have lots of specialist therapist staff. I am not saying that is a bad thing, but we do have specialist therapists, such as specialist CBT therapists, specialist psychotherapists and specialist systemic therapists. They are trained to deliver a particular intervention. If that is the case, it is more difficult to expect them to embrace or move to a new intervention type that is not their initial training.
Q194 Dr Wollaston: But that seems extraordinary. You would expect a surgeon to change their operating technique if there was different evidence emerging, so why would it be more difficult for a therapist to change the type of intervention they provide?
Dr Taylor: I would say it is because therapists are trained to deliver particular interventions. They are not broadly trained, as psychiatrists or psychologists are, to continue to assess the evidence base and to change their practice in line with the evidence base. It is a different type of training. It is specialising in a particular modality, which, if you know you need a lot of that modality, it is a good thing to be able to have; it does not require sometimes as expensive or intensive training, and therefore it is sensible. If you know you need, for example, a significant amount of CBT to address mild anxiety and depression in children, you want to have an availability of CBT therapists. So there are advantages to having people trained in a particular modality, but there are also disadvantages in terms of the flexibility of those staff to move forward if there are changes in the evidence base.
Q195 Dr Wollaston: Why is it so difficult for them to adapt and learn a new technique—a new therapeutic intervention?
Dr Taylor: It is because the training is quite long in particular therapies, so people do not particularly want to go back and start their training again if they have been training for four years to deliver a particular modality therapy, but I think there is some change with that. One of the aspects of the IAPT programme was trying to encourage people to move forward with training in different modalities, but my experience is, I think, less so, as I say, for psychologists, who, like medical doctors, and psychiatrists do a general training and then are expected to keep up to date with the evidence. My colleagues who are focused in a particular therapeutic modality would more expect, if that was not required any longer, to stop doing it rather than train again from the beginning.
Q196 Chair: We are trying to have a better integrated health service and it is quite clear from the Health and Social Care Bill that we are trying to bring things together. Do you think that training generally is out of date and that there is too much focus on particular disciplines and not enough on interface with other disciplines? Do you think, for example, that it might be something we should look at? We should look at just how the training is done. It sounds, from listening to your answers to Dr Wollaston, that it is all so rigid—these separate silos—and that there is almost a degree of defensiveness. It is not a criticism, but it is a statement of fact. Is that fair?
Dr Taylor: I think there is a degree of defensiveness, but I am not suggesting that we should not have people trained in particular types of therapy, in the same way that—I don’t know—for example, a general practitioner might want to refer to a physiotherapist who knows how to do physiotherapy. They are not going to suddenly start doing another type of therapy; that is their training. But you need to know how many physiotherapists you need. You need to have people who are generally trained, like psychiatrists and psychologists, to look at what the problems are, but then you also need to have sufficient therapists trained in particular modalities to deliver them. In terms of knowing whether we need to revisit the training, what we really need, as has been discussed here and elsewhere, is to revisit the epidemiology: what is our level of need? We are not clear. We seem to be feeling there is far more coming in. We need to look at the levels of need, the different presentations and use that to help plan what specific modality therapists we need and what else we need.
Q197 Grahame M. Morris: I think you were in for the earlier session where we heard about outcomes and impacts on the service of things that were happening. How do we measure the outcomes and the success of the CAMHS service? Is there a quantifiable measure that is applied in terms of the treatments to children and young people as to how effective they have been?
Dr Taylor: Certainly, there is a lot of interest in this but it still is not one of the main things that lots of services are assessed on. For example, there are consortiums such as the CORC, the outcomes research in CAMHS, where services can join up to ensure they are using particular standardised measures pre and post a child being referred to the service. So you are effectively looking at, “Does a child meet the clinical criteria for a diagnosis of x, y or z?” or being at risk of any diagnosis before and after coming to a service. That is one type of assessment. Obviously you can also look at whether the child keeps on returning. You can look at whether the parent and child think you are making a difference to them. We are collecting far more of that sort of data than we have done previously, but still in many trusts the data they are required to provide to the commissioners is not that data: it is how quickly they are seeing people and how many people they are seeing, which, as a colleague said to me the other day, is a bit like simply looking at whether the post office are picking up letters very quickly and how many they are picking up, but not checking where they are going.
Q198 Grahame M. Morris: I think Dr Myers mentioned how difficult it is or that there is a parallel with Sure Start, measuring their effectiveness, which you can do, and the value of that—the positive outcomes from that.
Dr Taylor: I think we certainly can measure effectiveness, yes.
Q199 Chair: Dr Kraemer or Dr Jones, do you want to come in on this at all?
Dr Kraemer: You have three separate agendas here. I want to talk about paediatric liaison in hospitals and Dr Jones wants to talk about perinatal mental health, so they are quite separate issues.
Q200 Barbara Keeley: Before I ask this next question, on the first question, is there anything culturally or in society driving this incidence of deliberate self‑harm and suicide that seems to be a part of the work? We have talked about resource constraints, and my next question is about resource constraints and cuts, and the impact that that is having, but is there anything else thought to be a driver of the degree of threat of suicide and deliberate self‑harm?
Dr Kraemer: I was not answering questions and you were not asking them when this question was asked before and I would like to make a comment about that.
Barbara Keeley: Yes, please do.
Dr Kraemer: There is a degree of insecurity among young people which is quite remarkable. I have been in my job for 34 years as a consultant psychiatrist and I have never seen so many people coming in in crisis, and these are not trivial crises: these are life‑threatening crises, children running on railway tracks and being brought in under section 136. It is right across all social classes, so there is a degree of social disintegration which we are witnessing at the front line which is unprecedented in the last two or three years. The number of emergency admissions to the paediatric department at the Whittington has about doubled in three years.
Q201 Barbara Keeley: That is interesting. We tend to view everything through the prism of resources, and of course they are important, but if there are other drivers it is worth knowing.
Dr Taylor: Not being an academic psychologist, I am afraid I do not know the answer to that question. I think lots of us are not sure. I would echo what others have said—that there is an increased presentation of people with self‑harm needing response. People are looking into the possibility of this being related to there being less effective earlier interventions, the possibility that greater and faster communication between young people related to increased use of media may impact on issues of security and insecurity, but also trends of how people manage and cope with their emotions. But I do not think we know. There needs to be more work done on this. We are the people who are providing services—ourselves and the colleagues previously—rather than researching into the causes. We would all love to have time to do that, but that is not what you get to do as a provider of services in the NHS.
Q202 Barbara Keeley: Perhaps you could expand. The actual question for the Committee was around that reduction in preventative services. Your written submission stated that many preventative tier 2 services have been decommissioned and that the referral criteria for access to tier 3 services have been tightened. Therefore, if a young person’s referral to tier 3 is not accepted, there may just be no other service for them to go to if the other services have been decommissioned. Could you expand on that?
Dr Taylor: Certainly, the experience of the majority or a significant proportion of our members in their trusts is that they have noticed that decommissioning of services. There is a question of whether that is why we are seeing more children and young people presenting with self‑harm. It may be that we might not have seen them if they had been dealt with earlier, but also I am aware that, for example, when people are referring to try to access tier 3 services they will certainly make sure they mention in any referral any remote incident of self‑harm because that is one of the things that gets you in. Because everyone has had to tighten up due to the increased number of referrals, people tend to try to prioritise young people who are self‑harming, but we are, I think at times, looking at a broader definition. That is not to minimise the concerns for young people who are behaving in any sort of way that is deliberately self‑harming, but we are seeing a lot of young people who are acting in some way that is self‑harming. People are noticing that and flagging that, and saying, “Now we need tier 3 input,” whereas perhaps previously they would have been seen in other services.
Q203 Barbara Keeley: Dr Kraemer, do you see any link with people not being able to be seen sooner?
Dr Kraemer: That is not a problem for us. We have to see them; they come in. They don’t have to reach any threshold. They will be admitted even if they feel suicidal. I have never met a single young person in all these years who did not need to talk about the state they were in, quite seriously. These children come from families of all social classes who have quite chronic problems in relationships—and quite distressing. Sometimes the young people have a sense of humour and you think, “My God, there is nothing much the matter with her today. What a state she was in last night.” But if you look at the trajectory and look at her story, you can always see there are quite serious problems, and, in a sense, we are doing preventative work, but in another sense we are already rather late in the day.
Q204 Chair: Can I come in on this point? I was quite struck by what you said about social disintegration at all levels—all classes. Can you point your finger at one particular cause, and to what extent do you think that electronic communication—Twitter, Facebook and all of that—has a part to play, and also access to pornography? Is that actually bringing about some of these problems we hear so much about now?
Dr Kraemer: It makes intimidation more alarming and more chronic. You can be teased in the playground and it has gone with the wind, but if you have got your photograph on Facebook then it stays there for ever. I do not believe these children are any different from the children I met when I started in 1980, but they have different means of upsetting each other—girls in particular. The medium is not the cause, but it certainly facilitates different ways of harming each other, of abusing each other, and that is what young children do. Some of these girls have been bullied into a state of despair because their attachments at home are not strong enough, so they rely on their friendships to be a family for them, and when that family crashes they feel they haven’t got any, until family then appears like magic in the paediatric ward the next day and maybe some restoration can be created then.
Dr Taylor: I have one follow‑on point with regard to the media. I completely agree with Sebastian that it is not the cause, but it is creating a different environment. I did read a very interesting paper recently when we were discussing this very issue also looking at there being some evidence that for some young people the greater accessibility to other young people across the world who have similar interests to them has increased their sense of not being alone, not being the odd ones out. We just need to bear in mind that it is a different way of accessing other people and having social interactions that has huge possibilities for greater isolation but also potentially, for some young people who were previously feeling disconnected, for connection. We need to be aware that the access to media is not a clear‑cut thing.
Q205 Dr Wollaston: Are you aware of any evidence for what interventions work in those cases? Should it be delivered within schools in terms of teaching young people how to cope with social media? Is there any evidence that that is effective?
Dr Taylor: Do you mean interventions regarding self‑harm?
Q206 Dr Wollaston: No, regarding if there is a link with distress in young people, as Dr Kraemer was talking about, and what actually works in that case. Is it delivering programmes of education in school?
Dr Kraemer: What is it they are trying to change?
Q207 Dr Wollaston: Just the points that you raised. I am myself aware of a number of young people who have been seriously harmed by things like sexting, for example, and, as you say, the fact that their image may be there on social media and they have no control over it. Is there any way that you feel we should be making recommendations about how we can help young people to cope with this?
Dr Kraemer: I think that is closing the door after the horse has bolted. It is more a matter of controlling these modern media, and they are pretty well uncontrollable, aren’t they? It is hard enough to get stuff taken down off Google.
Dr Taylor: The important thing is to think that the encounters that people have, the sorts of emotional harm people can do one another, are as they always have been, but they can do them these different ways for longer with less observation. What is difficult is that the adults parenting children have not grown up themselves being so familiar with these sorts of ways of communicating, so they are less clear about how you supervise, monitor and keep their children safe. They understand a bit about how you do that in the playground, walking to and from home, and if their child asks to go round to a friend’s house, phoning that parent and checking if they are someone suitable. We know how to do that in the real world. We are less experienced about how to do that in the virtual world. It is partly about equipping parents to think that it is a similar role and to talk to children and young people about who they talk to, when they talk to them and how they know who they are, but we are all feeling our way because it is not an environment many adults grew up with.
Q208 Chair: Thank you very much. Just coming on to definitions, do you think that the term “mental health problem” is poorly defined? Do you think we need better definitions of problems?
Dr Kraemer: How long is a piece of string? I am worrying about wanting to talk about the work we do at the Whittington. That question is the one I deal with every day working with paediatricians who think that mental health is a strange phenomenon because it is not easily defined, as you rightly say. So I do not define it. I just say, “What’s the problem here? What are we dealing with? What’s the matter with this child? Why are you asking me to see this child?” From our point of view in paediatric liaison, working in a hospital, we do not need definitions; we need conversations. I am really quite passionate about that. I could talk about this but I think it would not be dealing with the submission that I have sent in. I do not think it would help the Committee.
Chair: Thank you.
Dr Taylor: I think that might be a quote from our submission, so I feel I possibly should—
Dr Kraemer: I am sorry, I should not have answered.
Dr Taylor: No, no. But I am also aware that we have experts here from other fields.
Q209 Chair: Please let it be drawn out. We need this information. We need colour and depth as well.
Dr Taylor: As I say, I am only responding because I think it may have been asked because it was in our submission.
Chair: Yes.
Dr Taylor: The reason why that particular comment is in our submission is again related to how tier 3 services have, to some extent, been pushed into a corner, about how they manage with increases in incoming referrals. The corner they are being pushed into quite often is saying, “We will only accept this referral if the young person is suffering from a clear mental health problem or an identifiable mental illness.” The reality is that children and young people, like adults, show their distress in a variety of different ways. There are some classic ways we show distress—depression, anxiety and so on—but quite often young people’s distress does not fit neatly into a box. If it does not fit neatly into a box, sometimes that prevents them from accessing CAMH services. The comments were with regard to the need for access to CAMH services being related to the extent to which a child’s emotional distress or behavioural difficulties are significantly impacting on them rather than whether they have one clear, specific mental health problem, as those are not as well defined as we like to imagine they are.
Dr Taylor: I think, coming from a perinatal perspective, it is really important to be able to identify whether a pregnant woman has had a previous psychotic or serious emotional illness in her history. That is because of the risk of relapse with the stress of pregnancy and all of the hormonal changes that occur and so on in pregnancy, and whether or not the pregnant mother has emotional support. If you do not identify during that pregnancy her history and then refer appropriately to perinatal psychiatry and a team such as ours, then the risks of that woman relapsing and becoming very ill are very high. You only have to imagine what it is like trying to look after a newborn baby if you have flu—that is pretty difficult—but if you have a major affective illness or psychotic illness it is really, really difficult and dangerous.
Q210 Andrew George: I want to raise the issue of the creation of the paediatric liaison teams in acute hospitals. I see that this is something which is well established in some areas but not in others, and I want to get a view. I think, Dr Kraemer, they are well established in your hospital. To what extent has that development been seen as a critical aid in terms of capturing and supporting new cases as they present, and what lessons have you learned from their creation which can be rolled out in other parts of the country that are not fortunate enough to have them?
Dr Kraemer: It was a question that Rosie Cooper asked in the previous session that got me thinking about what was a good pathway for serious emergencies. This is an indirect answer to your question. That is, actually, where do you go in an emergency? You go to casualty. What happens in casualty if you are under 18? You go into a paediatric ward. If there is no mental health resource on that paediatric ward, then the child is an embarrassment, is frustrating paediatric staff, they are upsetting them and they are complaining. If there is a psychiatrist there—we have 24‑hour-a-day psychiatry to the paediatric ward—they are grateful. They know it is part of their job to look after under-18s in crisis—deliberate self‑harm and even psychosis. Some of them may need brain scans and the like, so they are in the proper place to be medically investigated. Then they will be pleased and they will do a good job. The paediatricians do a fantastic job in looking after seriously unhappy, disturbed young people because they have psychiatry on tap night and day. That is one point. That can only really survive if it is commissioned as part of a paediatric service. CAMHS is not going to provide this.
Q211 Andrew George: I know nothing of the role of the paediatrician in this respect, but are they sufficiently generalist at least to begin the process of providing some of the psychiatric support where young people present with a mental health problem in an emergency and without a psychiatrist on tap?
Dr Kraemer: Do you mean without the psychiatry on tap?
Andrew George: Yes.
Dr Kraemer: No. They will become frightened. A girl came in the other day, really a very sweet, thoughtful girl, but she absolutely knew that she had to die, so she frightened everybody. In fact she frightened me. It was one of the rare occasions when we actually needed an urgent tier 4 bed. The paediatrician and I saw this girl together with her mother and we got her into a tier 4 bed. My contention is that, because we are there, we are reducing the need for tier 4. For many of these young people who look dangerous the night before, within two or three days you can send them into tier 3.5. Nobody has mentioned it, but adolescent outreach is tier 3.5 in our locality, and it is very good and very quick.
Q212 Mr Sharma: Dr Kraemer, Cornwall has told us that they were unsuccessful in securing funding or enhancing their funding on the paediatric liaison. You know that. How have you succeeded in securing and maintaining funding for your services?
Dr Kraemer: We are very cheap. We cost £250,000 for a round‑the‑clock service. We have one full‑time psychiatrist, a part‑time psychotherapist and one junior doctor part time. It is cheap.
Q213 Mr Sharma: But you don’t compromise on quality.
Dr Kraemer: We don’t compromise on quality; no, it is consultant‑delivered. It is the consultants who do the emergency work during the day, and senior registrars and registrars at night. We increased our funding because the commissioners came to see what we were doing, thinking that we were doing CAMHS and we were just sitting in a hospital doing CAMHS clinics. They discovered, to their amazement, that it is a completely different service. Most of the children we see who are not emergencies don’t have visible mental health problems at all: they have tummy aches, are unable to walk, have terrible headaches, have out‑of‑control asthma, or out‑of‑control diabetes and so on—or they are younger children with feeding disorders, soiling and so on. These children would never get to any mental health service unless there was a liaison team there.
The answer to your question is that paediatricians have to pay for this themselves. It has to be in a paediatric budget which cannot be asset-stripped by CAMHS. CAMHS is under pressure, and that is the message you are getting from all these submissions. We are a tiny, invisible service, which hospitals, once it is supplied to them, really want, but they do not know about it until they have had it.
Q214 Chair: Looking at the reorganisation that has gone on, I was thinking about the A and E services in London and the consolidation—I am just trying to think which service it was—I think, with the cardiac service. That consolidation has resulted in the saving of 200 lives per annum. Do you think that with all these disparate organisations and poor communications what we really need is some form of hubs around the country—that we should consolidate mental services? Is that possibly the only way to find a solution?
Dr Kraemer: A solution to what problem?
Q215 Chair: To providing a better overall service to those that need it.
Dr Kraemer: I don’t know the answer to that because the point is if you close casualties it is further for people to go, but that does not mean to say they won’t get there. So, in principle, anywhere where there is a casualty and a paediatric department there should be a liaison team. If there are fewer of those, it is cheaper to provide possibly, but then further to go and presumably they see more patients, so I don’t know whether you have a saving in cost. It is beyond my scope to answer that particular question. But you have to have a casualty and you have to have paediatric beds to do the kind of work I am talking about.
Dr Taylor: Are you talking specifically about young people in hospital settings now or more broadly?
Chair: I was thinking mainly of that, yes, and I think the question has been answered.
Q216 Barbara Keeley: It probably seems obvious, but can you expand for us on why the 0 to 2 age range is considered so important for children’s mental health and for delivering preventative interventions? That is the first question. As I say, it might seem obvious given that we are committed to early-years interventions, but perhaps not.
Dr Jones: I think Sebastian mentioned a very important word earlier on, which is “attachment.” The weight of evidence from attachment research suggests that, if you can develop a little baby who is securely attached to their mother and other family members and father or partner by the age of 12 months, you have gone a long way to developing some resilience in that child. When I was listening to Sebastian and Jenny talking about the sort of presentations of violence against the self that they are seeing in these young adolescents, it does beg the question whether the kind of adolescent developmental process, which is complicated enough even for a securely attached child, is something that becomes overwhelming and disintegrating for some of the youngsters they are talking about. For me it makes sense to do everything you can in the first two years of life, particularly starting in pregnancy, to create that secure attachment and bond between a mother and baby at a time of critical brain development.
But it is not just about brain development; it is about emotional development. Babies learn how to do relationships by 18 months of life. You can tell the difference—I work with it all day every day—between babies that are failing to thrive emotionally and babies who manage to turn a corner and you see them start to enjoy being alive and obviously see the transformation in their parent. I think it is a very good economic investment and a very good emotional investment to really focus on pregnancy and the early years as a critical developmental stage in a family’s life and to ask the really serious question as to why there are not equal opportunities for services across the country for these mothers and babies, to really lodge that as an uncomfortable question in your minds, to think about ways to address that and to make local commissioners aware that this is a problem that needs to be addressed. It is not fair that it should be x amount of boroughs across the country who have access to that.
Dr Kraemer: Dr Jones did not ask me to say this, but this really needs to be heard. This is absolutely magnificent because what you are doing there is catching people before the rot sets in. All of us talk about early intervention, but actually here is somebody doing it for about £2 million. It is cheap.
Dr Jones: I did not mention a figure.
Dr Kraemer: No; maybe it is less than that—I don’t know—but, anyway, it is cheap compared with the costs of conduct disorder, depression and so on later in life. If you can find a way of promoting early intervention in the perinatal period of this kind, that would be a great coup for this Committee, I believe, because this is the best thing to do in health. It is not just about emotional development; it is about physical development as well. Children who are insecurely attached also develop more illnesses, become unhappy, delinquent and less successful citizens. This is an opportunity. Perhaps—again she did not ask me to say this—you should look at the film made for Channel 4, “Help Me Love My Baby,” which shows in three quarters of an hour how transformation takes place in people with very serious difficulties in relation to their babies. They can’t love them.
Barbara Keeley: I have more questions, but I think Andrew George wanted to come in on that point.
Q217 Andrew George: It is the other side of the coin in a sense. As Dr Myers, who is still present, will be aware, in places like the far west of Cornwall where you get occasions of post‑natal puerperal psychosis, or whatever, there have been many occasions when the mother is transported hundreds of miles for the high‑level support and intervention that she requires, and the baby remains hundreds of miles away from that mother. The need for mother and baby units is something which surely should be commissioned at a national level. You, Dr Jones, were implying in everything that you were saying the patchy nature of the local commissioning process. It seems to me that this is something that should be part of a national strategy rather than something that might simply fall off the end of the ability of the local commissioners to provide that service. Is that not right?
Dr Jones: I would call the Committee’s attention to a report by the NSPCC, “Prevention in mind. All Babies Count: Spotlight on Perinatal Mental Health.” It very succinctly addresses a lot of these questions about the complexity of commissioning. Our service is part funded by specialist commissioning now and also by child health commissioning of CCGs, so it is complicated. But in terms of thinking about the specialist mother and baby units, again this report will show you where they are located and how they are managed and so forth.
Chair: Thank you very much. Before I go back to Barbara Keeley, we are nearly at the end of the session, but if there is anything you want to say that has not been said, please say it.
Q218 Barbara Keeley: The second question is about asking you to describe the approach your service takes and what outcome it delivers, how that differs from other perinatal services and what role health visitors play in that, if you could just describe that for us a little bit.
Dr Jones: We are a multi‑disciplinary team with two consultant perinatal psychiatrists and another full‑time doctor, community mental health practitioners and a group of what we would call perinatal psychotherapists and maybe clinical psychologists and systemic therapists, child and adolescent psychotherapists, but they all have a lot of expertise in terms of infant development and working at the earliest sort of time. It is a well‑resourced service in that it is a community mental health service. We have access to what is called the Homerton mother and baby unit in east London, where our in‑patient admissions tend typically to go—mothers we refer for in‑patient admission. In many of the cases that we are working with, at least at the initial stage, there will be the involvement of one of the psychiatrists, one of the therapists and the community mental health practitioner all together. In a sense, the mother gets a bit of a safety net of the team approach during her journey.
In thinking about the outcome, I want to come back to thinking about the training you mentioned earlier. Something that has to be present in all of the people working at this time—because it is an incredibly risky time and I want to underline that—whether you are a community mental health practitioner, a therapist or a psychiatrist, is an incredible ability to manage high levels of risk and anxiety, to be very steady and very mindful of one another and the emotional burdens that are carried by the team. When thinking about outcomes, if our consultant perinatal psychiatrists were here, they would say, certainly in terms of the psychotic mothers who have had a history of psychotic illness and/or might presently have been psychotic, they respond very well to treatment at this time and you may find that they have a lesser rate of relapse afterwards, which, from a mother’s point of view, is a significant improvement. Fewer of our mothers are referred back to community CRT adult mental health teams—community recovery teams—after they have had a spell in our service. The service satisfaction questionnaires that we issue indicate that mothers are deeply grateful if they can be helped at this time. There is often a high motivation to make use of help, so we do find that as well.
Q219 Barbara Keeley: I mentioned health visitors. Is that a source of referral and do you work with health visitors?
Dr Jones: Yes, indeed. We get most of our referrals from midwives. They are from midwives, GPs and adult mental health, and quite a few from social care because, you can imagine, there might be an unborn baby who is subject to a child protection plan. But once a baby is born and if they have not been identified earlier on or difficulties have not emerged until post‑natally, then, yes, health visitors will be able to refer. Importantly, mothers can self‑refer to the service as well, which is not something that is always available.
Q220 Barbara Keeley: You talked earlier about the patchy nature of the existence of services like yours. I don’t know if you would go so far as to say that they are rare in the UK and, where available, are often small and poorly resourced. What started the development of the services, if you like? How did they spring up and what are the barriers to service development? Is it just financial or is it a lack of understanding in commissioners that they need a service like this? Where did you come from, if you like? How did your service spring up. and where there are not services or they are very patchy and under‑resourced, why is that?
Dr Jones: There has been huge progress since 2001, when this thinking first started in our area, to develop something that focused particularly on infant mental health. I have been fortunate enough to work within an organisation which fundamentally believes in and supports the earliest possible intervention in babyhood, really, and I think that organisational support has been invaluable and there were certain committed individuals within the organisation who basically got it. They realised that this is a no‑brainer; it just makes sense to invest here. That was very helpful. My service manager Jo Luckie is present here today and would have much more to say on this because she is the co‑ordinator of the pan‑London perinatal network, but, generally, there has been huge progress over the last 10 years in knowledge and thinking about perinatal services, particularly in London. There is increasing discomfort and indeed a good deal of understandable envy felt by some areas in relation to our service because they do not have as big a team present. I think progress is being made but there is a long way to go. Some of the London boroughs might only have 0.5 of a consultant perinatal psychiatrist’s time for their patch; some won’t have anything at all. That is a bit alarming.
Q221 Barbara Keeley: What stops them—just lack of a belief that they need it or choosing to spend resources elsewhere?
Dr Jones: Someone needs to say that the services have to be there, just like you expect an A and E to be available if you have a car accident or you expect a neonatal intensive care unit to be available if you have a premature baby. You should say, “I expect in this area that to be available.” If you have bipolar affective disorder and you are at risk of breaking down very quickly after birth, you don’t want just to be with ordinary adult mental health; you want to be with a specialist perinatal psychiatrist who knows about the medication and has managed that during your pregnancy, who knows about what to do if you need admission. You need specialist knowledge, not just general psychiatry.
Q222 Barbara Keeley: How would the MPs here and more generally find out what their local service was like, whether it was a good service, adequately resourced or whether it was one of these with half a consultant or, in fact, no consultant? That is with the CCG, is it?
Dr Jones: I think work is being done nationally to try and collate that information by the Royal College of Psychiatrists. They have a perinatal division, but I can certainly make available to the Committee, following this meeting, some reports that would be very helpful.
Barbara Keeley: That would be very helpful; thank you.
Q223 Chair: That is a very convenient point for us to—
Dr Kraemer: Can I make a point? You did say there was a chance to speak if something—
Q224 Chair: Yes. I was going to say that is the end of the questioning, but if you would like to make any further comments, please do.
Dr Kraemer: I have read all the submissions and I am deeply sympathetic to the Committee in having to read so much material, some of it really quite depressing. So I wanted to be a bit enthusiastic about something that actually does work. I have decided today that it is tier 3 and three quarters that we are at. Since we never had a tier in paediatric liaison, we are nearly at 4 because we are in‑patient, so we are looking after children who are hospitalised, although we do not have psychiatric nurses. It is really a question of consciousness, very similar to the perinatal question. When people realise that many children in hospital require mental health support, it is a no‑brainer, but they do not realise it and then they wonder why these children are coming back again and again in diabetic ketoacidosis or whatever, and these are unhappy children. It is not that their diabetes is worse than anybody else’s; they are unhappy children for a good reason.
There are four submissions, I think, out of the 40‑odd, which mentioned paediatric liaison, so it just shows what a minority it is. Yet if you go to page 7 of my submission, there is 10 years’ worth of national recommendations about paediatric liaison. Everybody is saying the same thing: “It’s a good idea. What about doing it? What about thinking about it?” As long as it is included in paediatric commissioning, it will happen. If it is taken from CAMHS commissioning, it will not happen.
Q225 Chair: Thank you. Dr Taylor?
Dr Taylor: If we are going to move things forward we need a clearer picture, not just from provider units but at population level, about what we are seeing at the moment in terms of need. We then need to ask service commissioners to clearly demonstrate how they are going to meet that known need, both in terms of specific interventions for specific disorders—we do have a lot of information about that and we are not requiring people to evidence that they are doing that—but, also, in situations where, as I say, the difficulties for many children and young people are not one specific disorder that fits neatly into a box, we need to be clear that we are able to provide services that are clearly based on initial psychological principles tailored for individuals and monitored to see if they are making a difference or not. I am afraid I don’t think we can do that with just single modality therapy staff.
Q226 Chair: Dr Jones?
Dr Jones: I think I have said a lot.
Chair: Thank you. On that happy note, three doctors, thank you all very much indeed.
Oral evidence: Children's and adolescent mental health and CAMHS, HC 342 31