Written evidence submitted by Ian M Goodyer MD FRCPsych FMedSci
Ian M Goodyer MD FRCPsych FMedSci, Professor of Child and Adolescent Psychiatry, Department of Psychiatry, University of Cambridge.
Honorary Consultant with the Cambridge and Peterborough NHS Foundation Trust.
I have been a consultant and honorary consultant in Child and Adolescent Psychiatry in the NHS since 1983. I have held senior operational management positions and was for 5 years a non-executive director on the Board of the Cambridge and Peterborough NHS Foundation Trust. I have provided evidence on Child and Adolescent Mental Health to the British and Canadian Governments, the WHO and the UN. I have been Secretary-General of the International Association Child and Adolescent Psychiatry ad Chairman of the UK Child Psychiatry Association.
Background
Information in this brief report is based on 2 investigations from the University of Cambridge Developmental Lifecourse Research Group. These are a recently completed five year programme investigating Adolescent Mental Health and Service Provision and an ongoing longitudinal study of 1243 14 year olds, the ROOTS cohort, now entering their 23rd year. The work was and is being undertaken within the County of Cambridgeshire which is home to approximately 900,000 individuals of whom an estimated 80,000 are between the ages of 11 and 19 years and more than 160,000 are 18 years or younger. The county is one of the fastest growing in the UK with one of the highest incident increases in families and young people.
The focus of the applied health research work summarised below was on use of mental health and local authority services by young people and their families and the transitional experiences of clients leaving these services at 17 years of age. An additional element investigated whether the evidence base had been perceived as of value to policy makers. Selected preliminary findings from the ROOTS Cohort focusing on bullying/victimization and the impact of service use are also provided although both remain unpublished and therefore not yet subject to scientific peer review. Finally I provide personal commentary regarding the condition of current CAMHS in Cambridgeshire including the City of Peterborough.
The Evidence Base and the making of Child Mental Health Policy
Summary
Government documents make very little direct reference to the available science. Around three-quarters of citations in published Government papers were to articles reporting only a single study. An explicit rationale for evidence selection or citation by Government was rare.
Child mental health policy documents published by the UK Government between 2000 and 2011 were scrutinized together with all published peer reviewed literature between 1980 and 2011. Less than 1% of the literature is cited in government documents. There is little or no information on the sources that informed these documents. Decisions regarding evidence selection for use in informing child mental health policy development should be explicitly made in Government reports. This would allow future governments, their advisors, service professionals and users to properly evaluate the contribution of the evidence base to Government plans and policies.
General practitioner perceptions of CAMHS
Summary
There are longstanding functional and structural weaknesses in the mental health services for children and young people. This is reflected in poor multiagency cooperation at the primary care level and the lack of agreement and acceptance of changing inclusion/exclusion criteria for referrals to specialist child mental health services. GP-friendly guidelines and standards are required that will aid in decision-making and help with understanding the referrals process. There is an urgent needed to develop functionally valid tools and clinical protocols together with reviewing health service d local authority structures. These changes would aid GP’s and others in primary care to recognise mental illnesses in young people and inform clinical decision making.
This study investigated general practitioner (GP) perceptions and experiences in the referral of mentally ill and behaviourally disturbed children and adolescents to local secondary services in the NHS. Quantitative analyses on patient databases were used to ascertain the source of referrals into Child and Adolescent Mental Health Services (CAMHS) and identify the relative contribution from GP practices. Qualitative semi-structured interviews were then used to explore challenges faced by GPs in referring to CAMHS. GPs were chosen from the five localities that deliver CAMHS within the local Trust (Peterborough City, Fenland, Huntingdon, Cambridge City and South Cambridgeshire). For the quantitative portion, data involving 19,466 separate referrals were used. Seven GPs took part in the qualitative interviews.
The likelihood of a referral from GPs being rejected by CAMHS was over three times higher compared to all other referral sources combined within the Cambridge and Peterborough NHS Foundation Trust. Interviews showed that detecting the signs and symptoms of mental illness in young people is a challenge for GPs. Communication with referral agencies varies and depends on individual GP relationships. GPs determine whether to refer on a mixture of the presenting conditions and their perceived likelihood of acceptance by CAMHS; the criteria for using the latter were poorly understood by the interviewed GPs.
Bullying and Victimization
Summary
Two forms of bullying are currently recognised: physical assault and verbal abuse. Self reported exposure by adolescents to bullying when a child is associated with mental illnesses occurring over the teenage years. This association is not explained by a prior history of exposure to family adversities in the childhood years. The mental illness risk is currently best considered as arising from school and peer group environments. Teenage focus group feedback suggested that social media bullying is a 24-hour form of verbal victimization. The risks from this are very poorly understood. Policy and protocols going forward that aim to reduce bullying/victimisation will need to focus on non familial sources of risk.
This work is from the ROOTS cohort where 452 (260 female, 192 male) 17 year old students completed a self-report peer victimisation questionnaire on who reported whether they had or had not been bullied at primary school between the ages of 5-11 years. The responses were examined with respect to exposure to childhood adversities before the age of 11 years, quality of friendships and family relations between 14 and 17 years and depressive symptoms at symptoms years.
Both types of victimisation were un-related to exposure to childhood family adversities or family functioning when a teenager. Physical victimisation in primary school had a direct risk for depressive symptoms by 17 years. Relational victimisation had both a direct effect and was associated with poor friendships in adolescence with this combination of factors also associated with depressive symptoms by 17 years. Reducing verbal relational victimisation in the primary school years may reduce depressive symptoms and improve friendship formation in the adolescent years. The focus group findings highlight the round the clock risks for verbal victimisation in the adolescent years, which may be an added vulnerability for those already exposed to similar bullying in childhood. (full report available from the research unit).
Discharge From Adolescent Mental Health and Care: the subsequent 12 months
Specialist CAMHS services in the NHS and community services in the local authority are discharged at the age of 17 to 18 years. In theory if they remain unwell they undergo a transition to adult services. In reality transition for those still in need is poorly implemented and monitored regardless of which service they attended. As a consequence many are likely to enter late adolescence and early adulthood with their needs unmet despite being previously known to adolescent services. A service redesign model should be implemented that does not fall at the most hazardous time for young people.
Adolescents (n=53) leaving NHS CAMHS or local authority care were followed over a 12-month period. At discharge 34 (64%) were still mentally ill. Overall only 3 (6%) were recovered (0 or 1 symptom and free of psychosocial impairments) at follow-up. Impairments in mental health, lack of employment, education or training and low preparedness for discharge was associated with poor outcomes. The findings suggest the current organisation of mental health and care services may not be fit for purpose and even unwittingly contribute to persistent mental illness and poor psychosocial outcomes. A redesign of services should consider a model where the timing of transition does not fall at the most hazardous time for young people. A youth focused service across the adolescent and early adult years may be better placed to avoid young people falling through the service gap created by poor transitional management.
Current State of CAMHS
Current CAMHS in Cambridgeshire is subject to the same proportion of efficiency gain as the rest of the mental health services. In the county and the City of Peterborough combined I estimate there has been approximately a 25%-30% loss in clinical staff and front line support staff over the past 4 years. The NHS Trust involved has filled service gaps at times of severe shortage with short-term appointments.
Clinical and administrative staff loss by skill and profession over the last 4 years has occurred within each of the 4 clinics covering the Geographical locus. There appears to be little tier 2 left at all but the baseline of that resource was not large in this location numbering just a handful of mostly nurse practitioners. The absence of modern IT and informatics means valid clinical data is not available to providers or commissioners. Therefore purchaser-provider conversations can only occur based on the simplest of performance variables such as total number of referrals and number of contacts. This is a wholly inadequate information base on which to determine a service specification and its cost on behalf of the Cambridgeshire population. Cost effectiveness, even when available for a given treatment, seems to be ignored by provider and purchaser alike. This is probably because Trusts are mandated about what data to collect for monitoring and performance purposes and this does not include clinical information on disorders, treatments, outcomes or even outputs. In summary the management does not and cannot determine what its workforce does or how successful it is at doing it. As a consequence commissioners cannot know what it is neither they have purchased nor if it has been cost or clinically effective.
Are CAMHS and Social Care Efficient and Effective
The past decade is associated with a marked increase in clinically meaningful research data for service use. Increasing access to psychological therapies has been one positive outcome from the acceptance of these research findings. Implementation of family based treatments has been another. Clinical practitioners do attempts to adhere to NICE guidelines where resources permit. Overall however clinical implementation of proven effective treatments as well as management protocols for treatment resistance and non-compliance are noticeably absent in daily practice. They also appear to be of low value to the management team although my personal experience is that commissioners would very much value the equivalent of a ‘product inventory’ of treatments and clinical best practices with attached proposed costs.
Cambridge CAMHS has some of the most outstanding examples of best practice in the UK. This is particularly true for the treatment and management of the depressions, hard to range adolescents engaged in substance misuse, early onset psychoses and mental illnesses in the learning disable population. There is also a UK leading multisystem therapy service for failing families whose children risk being taken into care. There are protocols and manuals for treatment that have emerged from our research and been successfully implemented into some routine clinical practice. This demonstrates that protocol driven and quality services can be delivered in busy perhaps over stretched services providing clinical staffs are well supported as they have been by the research unit here in Cambridge. Implementation of best practice and protocol driven treatment is noticeably harder and even absent in services where staff are not well led or supported. The volume of referrals running at >30 per week and a mandatory focus on assessment as the performance index rather than treatment by Trust management puts clinical effectiveness at risk in favour of high throughput.
I do not know if clinical complexity has increased because diagnostic and impairment data are not recorded by the Trust (they are trialing this in other services at the moment) is not collected. Using our research trials data however makes it clear that severe depressive illnesses are no more complex now than they were a decade ago. Anecdote from mental health nurses involved in assessing referrals is that both psychotic like symptoms and self harm are being revealed more often by young people and this may be a trend indicating more severe mental illnesses emerging or at least being referred more often.
17 March 2014
References
Hinrichs S1, Owens M, Dunn V, Goodyer I. General practitioner experience and perception of Child and Adolescent Mental Health Services (CAMHS) care pathways: a multimethod research study. (2012) BMJ Open 2(6). pii: e001573.
Akister J, Owens M, Goodyer IM. Leaving care and mental health: outcomes for children in out-of-home care during the transition to adulthood. (2010) Health Res Policy Syst 12;8:10. doi: 10.1186/1478-4505-8-10.
Dunn VJ, Abbott RA, Croudace TJ, Wilkinson P, Jones PB, Herbert J, Goodyer IM. (2011) Profiles of family-focused adverse experiences through childhood and early adolescence: the ROOTS project a community investigation of adolescent mental health. BMC Psychiatry 7;11:109.
Reports Available From The Author
Gibson, J., Kelvin R., Goodyer IM (2014) A call for greater transparency in health policy development: Observations from an analysis of Child and Adolescent Mental Health policy. Journal of Evidence and Policy - in press.
Gibson J., Van Harmelen A., Owens M., Dunn V., Goodyer IM (2014) Friendships and Family support differentially mediate the effects of peer victimisation and early adversity on depressive symptomatology in adolescents. Unpublished report: the Developmental and Lifecourse Research Group, University of Cambridge.