A REVIEW INTO the provision of Child and Adolescent Mental Health Services (CAMHS) in the country has found that the UN Rights of the Child may have been breached for children with mental illness.
The report, authored by the Inspector of Mental Health Services, Dr Susan Finnerty, was published by the Mental Health Commission (MHC) today.
It states that long waiting lists, lack of capacity to provide appropriate interventions, “lost” cases, lack of emergency and out-of-hours services, difficulties in accessing primary care and disability services and the absence of monitoring certain medications all point to a possible breach of Article 24 of the UN Convention on the Rights of the Child, which was ratified by Ireland in 1992.
The publication of the report follows an interim review by the MHC, published in January of this year, which found that a large number of children and adolescents seeking mental health treatment don’t receive necessary follow-up care, with many ending up “lost” in the system.
Speaking at the launch of today’s report, Finnerty said it was important to note that significant improvement has happened since the review began, including the appointment of a national clinical lead for CAMHS.
“During the review, I found that there were some areas where CAMHS was provided in a safe and effective way. But we also found other areas where there were significant challenges in providing the services that were effective, efficient and safe,” she said.
“I found there was a lack of effective corporate governance in HSE CAMHS. There were gaps, especially in the area of managing risk, with little realisation or acknowledgement that there were serious issues in CAMHS.”
She said there was a “knee-jerk reaction to crises” such as the Maskey report and the interim report, which provided a bonus of funding to fix the immediate problem.
“But this is not sustainable, and only addressed local problems. This has resulted in propping up a failing system that needs a radical overhaul.”
A review was carried out of 1,178 files across all CAMHS teams between January 2021 and March 2022 while a review of CAMHS teams’ facilities was also conducted.
The review team also met with all 75 CAMHS mental health teams and six speciliast teams, individual staff and management within CAMHS, and parents and young people with experience of CAMHS services.
The report highlights that there is no ring-fenced budget for CAMHS, which has to compete with other mental health services for resources.
Currently, the HSE cannot provide a report on its annual budget and expenditure within CAMHS, but it has estimated that the current budget is €137 million, or around 12% of the overall mental health budget.
In the last six years, €22.6 million of development funding has been directed to enhance youth mental health, and while this has “resulted in positive developments”, the report states that there is evidence of under-resourced CAMHS teams across the country.
It states that the lack of governance in some areas is contributing to “inefficient and unsafe CAMHS” through failure to manage risk, failure to fund and recruit key staff, failure to look at alternative models of providing services and the failure to provide a standardised service across and within CHOs.
Risks were not identified across a number of Community Healthcare Organisations (CHOs) due to a lack of auditing and review. The report states that there were two processes for management and escalation of risk at team level, with “little or no information fed back on what actions were taken”.
Some teams were frustrated with this, telling the review that they did not “bother” to escalate risk anymore because they felt that there was no point.
“This resulted in a haphazard approach and under-documenting of risks and minimalist generalised actions record on the CHO risk register,” it states.
It was also found that in some teams, there was limited understanding of what constituted a risk, how it was assessed and how it was escalated.
Two-thirds of children in CAMHS teams had a key worker, but the report found that care planning was “either absent or of such poor quality as to be meaningless” in many teams.
Risk assessment and risk management was not documented in clinical files in many cases.
“We found that there were no care plans at all in some cases and of the care plans that were there, what I mean by meaningless is that they would have maybe two or three words in them, there would be no action plan, there would be nobody who was overseeing what was happening, and they were really just tokenistic in those cases,” Finnerty said.
“Having a care plan in CAMHS is highly recommended by the CAMHS operational guidelines. Unless there’s a particular reason, a care plan must be in place for each child, so basically, what we’re finding is that some services are not adhering to the national guidelines around care plans.”
The report also found evidence that some teams were not monitoring antipsychotic medication in accordance with international standards and that some children were taking medication without appropriate blood tests and essential physical monitoring as a result.
These findings were escalated to the appropriate clinical lead, which resulted in a review of the identified files. Following the review, the HSE reported that there was no evidence that any child was harmed or suffered side effects from their medication.
Digital infrastructure was found to be absent in three CHOs apart from the use of Excel spreadsheets or Word documents, while only one CHO had electronic records.
Most services did not have an IT system that manages appointments, schedules rotas, maintains clinical files and provides reports on activity, despite these systems being in place in comparable countries “for many years”.
Finnerty said the HSE told the review that they are implementing a particular system across the country for IT.
“But that doesn’t seem to have moved very swiftly and certainly in the year and four months that we’ve been doing this review, nothing has changed,” she said.
“In the interim, the HSE were going to put in a particular IT service for CAMHS. That hasn’t happened. I’m not sure why.”
The report also found that most teams did not use Healthlink, which contributed to paper-based clinical files being “frequently disorganised, incomplete, sometimes illegible, with little logic to the filing of documents within them”.
Finnerty said that staffing is deficient in “almost every area across Ireland, with teams working with levels of staffing way below what they should have to offer a safe and an efficient service”.
The vast majority of CAMHS teams were found to be significantly below recommended staffing levels, with some being 50% below staffing.
The report states that this was especially apparent in health and social care professional staffing, where there were deficits in occupational therapists, social care leaders, advanced nurse practitioners, clinical nurse specialists, psychologists, speech and language therapists and social workers.
This resulted in long waiting lists and a lack of staff capacity to carry out many interventions.
“We met staff who were working beyond their contracted hours, who were burnt out and frustrated by not being able to provide at the time of our review, what they saw as a safe and effective service,” the report states.
Finnerty said that availability of staff is not improving and is unlikely to for some time.
The HSE needs to think of other ways of delivering CAMHS that does not depend on a model that is 17 years old with rigid structures that do not address the needs of children.
She also said that there is “a postcode lottery” in CAMHS with “very little access” to CAMHS depending on where the young person lives.
Inspectors were informed that one team had 140 “lost” cases, while another team were attempting to identify an unknown number of cases that had been lost to follow up following a change in staffing.
“The HSE have assured us that all children and young people have been identified and their care reviewed and that no harm was found to have occurred as a result of being lost to follow-up,” the report states.
In a statement today, the HSE said it had completed a review of all open cases which had not had follow up appointments in the previous six months, and of those who had been prescribed neuroleptic medication.
A total of 576 open cases were identified. “We have contacted all of these, ensured they are receiving appropriate care and we have not identified harm caused to any of these individuals,” the health service said.
The report also points out that vulnerable groups of children, including children in the Traveller Community, asylum seekers and refugees, had more difficulties accessing services.
It states that young Traveller and Roma remain “largely invisible in mental health policy and service delivery”, while there is a risk that without clinical leadership in mental health of asylum seekers, refugees and migrants, “young people will not receive the most appropriate care and treatment.”
The report makes 49 recommendations in total.
Primarily, it recommends that the immediate and independent regulation of CAMHS by the MHC must be put in place “to ensure the State and the HSE act swiftly to implement the governance and clinical reforms to help guarantee that all children have access to evidence-based and safe services, regardless of geographical location or ability to pay”.
The Inspector’s independent #CAMHSReport which she commenced in April 2022 - and included the publication of an interim report in January 2023 is now complete with 49 recommendations.
— Mental Health Commission Ireland (@MHCIreland) July 26, 2023
👉 https://t.co/a2Ib51NVoQ #CAMHSReport pic.twitter.com/v6mXmhl5Mb
The implementation of the recommendations must be monitored by the Mental Health Commission, which publishes a yearly report on the progress of implementation.
It also recommends that there must be oversight of CAMHS and all other mental health services for children and adolescents by the HSE Health and Safety Committees.
A comprehensive strategy for CAMHS and all other mental health services for children must be prepared and approved by the HSE Board “due to the seriousness of the concerns raised by Dr Maskey’s report and this report”.
Among the other recommendations, the report states that the health service should reinstate the post of National Director for Mental Health in the HSE “as a matter of urgency” while alternative models of care must be considered by the HSE in providing clinical leadership.
It recommends that each CHO must have a clinical director for CAMHS and that each team must have a team or clinical coordinator dedicated to coordinating children and young people’s care.
It also recommends that the care and treatment provided by CAMHS should be standardised across and within CHOs so that each young person has the same opportunity to access the most appropriate treatment according to their need.
In terms of access to CAMHS, the report states that all children and families should be able to access an urgent mental health assessment at a time of crisis that is provided “in a safe suitable environment and delivered by trained supported staff”.
It also recommends that each major hospital and emergency department (ED) should have a dedicated liaison CAMHS, supported by an on-call CAMHS team that is accessible 24/7.
The full report is available to read on the MHC’s website.
Chief executive of the MHC John Farrelly said that while regulation will make a difference, there needs to be a CAMHS strategy put in place.
“We have no strategy for CAMHS in Ireland and that strategy would have to be integrated with all the other services, a State response,” he said.
“It needs to be signed off at HSE level and I would say the highest level of the State and then we are happy and prepared to monitor the implementation of that strategy. If the strategy doesn’t happen, if it’s not monitored, then I couldn’t provide assurance with you.
“If the strategy does happen and we are given the powers to monitor, I would provide assurances that this can be fixed and fixed fairly rapidly.”
MHC chair Dr John Hillery said the review is the “most important report” the commission has ever done.
He said the commission wants to be given interim regulatory powers to follow up on Finnerty’s report.
“We have said that, and we will keep saying that. This is too important to wait for the new Mental Health Act,” he said.
“Obviously, that’s an issue for the Cabinet as a whole and for the relevant ministers. We do know that the Taoiseach has focused on youth poverty as an issue and this is part of that or very allied to that, so we will be looking at the Taoiseach to take a lead on this.”
Finnerty said the HSE should seriously look at the way CAMHS has been delivered.
“We have 75 teams plus six specialist teams, and we’re trying to recruit people to fill 11 full-time equivalents on each of those teams and at the moment. That is not possible. We can’t do it because of the shortage of staff and the recruitment problems,” she said.
We need to look at a different way of delivering CAMHS. We can’t continue to do what we’re doing at the moment. just putting in money where there are crises.
“Realistically, just saying ‘well, we can find staff’, we’re not going to be able to find staff. That’s a fact, so we have to move on from that and see what the HSE can actually put in place to deliver a safe and efficient service.”
In a statement this afternoon, the HSE welcomed the publication of the report and acknowledged the “real concerns” it raises regarding delivery, staffing and governance and specific concerns regarding young people in the care of CAMHS.
“We are genuinely sorry for anyone who has had a bad experience of our services. It is the responsibility of all in the HSE management, medical, nursing, allied health professionals and administrative staff to work together and change if we are to make services more responsive in both access and quality of outcome,” the statement said.
Damien McCallion, HSE Chief Operations Officer, said the report points to deficits and shortcomings in the service provided to children and families, “and we acknowledge these and have a programme of work now to address these issues”.
McCallion said the health service is aware that improvements still need to be made and that it is determined to make substantial changes and improvements in its services.
“Our CEO and national leadership will be having detailed discussions with the Commission to ensure our plans are realistic, timebound and achievable and we have the full support of the Department, Minister Butler and Minister Donnelly in that effort,” he said.
The review was ordered in January last year after the publication of a report into the care of more than 1,300 children who attended the HSE-run South Kerry Child and Adolescent Mental Health Services.
The report, authored by Dr Seán Maskey, found that 46 of the children suffered “significant harm” while attending the service and that a review of 240 young people showed the service did not meet the standards which it should have.
It also found that 227 children being treated by a non-consultant doctor employed at the service were exposed to the risk of significant harm due to the doctor’s diagnosis and treatment of them.
These issues included sedation, emotional and cognitive blunting, growth disturbance, serious weight changes, metabolic and endocrine disturbance, and psychological distress.
In February, HSE chief operations officer Damien McCallion apologised for failures in mental health provision for young people and conceded that some children are still waiting too long to access services.
To embed this post, copy the code below on your site
have your say