How mental health services can be improved for young people

It has been reported that children in England will be seen by NHS mental health services within four weeks, as part of a Government pilot.  The consultation on the preliminary paper will run for around 12 weeks and will see additional funding for mental health services (even though the increase in overall NHS spending is projected to be below inflation for the next two years), mental health leads in schools in addition to greater emphasis on reducing waiting times, and setting maximum waiting times for mild and less severe cases.  There will be trailblazer sites and funding pressures mean it won’t be UK-wide until 2021. The new measures are part of a £300m investment by the Departments of Health and Education although it is not clear whether the 4 weeks target would be for assessment or for treatment. Mental health campaigners have been increasingly asking the government to commit to increased funding for child mental health services and for a greater focus on wellbeing in schools in the upcoming green paper on Child and Adolescent Mental Health Services (CAMHS).

Yesterday I chatted to Gamal Fahnbulleh on Sky News about the story.

There is more than one split going on within government at present. Whilst pro-Brexit and anti-Brexit ministers might be at loggerheads at the heart of government there is also a split about the level of additional funds to be allocated to public services such as the NHS.

The Health Secretary Jeremy Hunt is fighting a battle with the Treasury Department in seeking to secure additional funding for the NHS, and particularly for mental health services, and specifically for young people’s access to services.  The Treasury are seeking assurances from Mr Hunt that the NHS is leaner and meaner in implementing efficiency savings before agreeing to additional taxpayer funds to meet increasing need.

Mr Hunt can point to savings already in estates management, workforce planning, more collaborative procurement and shared services,  reduced agency nurse costs (producing around £800m in savings), greater use of generic drugs and other efficiencies in back office functions.  These savings are re-directed back onto the front-line. Progress has also been made in making in-hospital care safer and dealing with infectious bugs for in-patients. The NHS is now viewed as a safe healthcare system by numerous health think tanks and watchdog bodies. However, mental health services are playing catch-up given the underfunding over the recent years and this is where the Health Secretary is facing an uphill task with the Treasury.

It is clear that awareness of the unmet needs of mental health is far more prominent now in political circles as well as in the NHS itself. The difficulty, however, for Mr Hunt is that demand is continuing to rise, and will only increase in response to stigma reducing campaigns such as the Heads Together campaign, and any increase in funding is difficult to notice on the ground.

Working with children involves combining medicine and therapies and an emphasis on multi-disciplinary working and involves a multi-agency approach. That is why their therapeutic journey often needs to start with a visit to their GP and then contact with secondary services. Psychotherapy might follow as part of a integrated treatment plan.

Young people are increasingly at risk of mental health disorders for a number of reasons but just consider some of the statistics for self-harm.  Admissions to A&E departments are up 50% over the past 5 years for under-18s. About 77% of A & E, or hospital admissions, for self-harm were made by girls in the years 2010-16. The sobering statistics are that at least four young people in every secondary school class in England are now self-harming.  The Children’s Commissioner Anne Longfield recently told the Commons Health Select Committee that children as young as 13 felt they could only access support from mental health services by attempting self-harm.

What’s needed in children’s mental health services?

Yes, there needs to be parity of esteem with physical health care but this requires a shift in thinking and priority. It takes a lot of courage for a young person to reach out for help, but too often that help is not immediately available. In a mental health service that is in crisis clinicians will prioritise those with diagnosable conditions for treatment. The indirect message for many young people presenting with problems has often been to effectively come back when sicker. We should be aiming to have higher clinical outcome measures for treating all mental health conditions, not just the most severe cases.  It should also be appreciated, however, that emerging psychosis is harder to identify than cancers, for instance, so achieving 100% targets in mental health might be more difficult than in physical health. The reality is that it is harder for psychiatrists to get people into their clinic than it is for oncologists to get cancer patients into their clinics.

More above inflation funding is needed to account for ever rising demand and to compensate for years of underfunding. Demand in the NHS overall is variously described as rising by 4% annually yet funding increases next year is projected at 0.9% and neutral the year after.  That level of funding will require massive increases in productivity in order to expand services. Additionally, mental health budgets need to be ring-fenced so that funds are not redirected by NHS Trusts to deal with crisis situations in local hospitals.

Early intervention targeted campaigns need to be boosted. It is thought that approximately 50% of all life-long mental health problems first appear by the age of 14. Early intervention is, therefore, critical as are school health promotion and well-being campaigns. Such early intervention campaigns will ultimately boost the economy and the longer term NHS budget by tackling lifelong conditions earlier, thereby making long term savings with better clinical outcomes.

Better statistics for mental health services are needed.  It was in 2004 that witnessed the most recent comprehensive national prevalence study of children’s mental health. This was conducted at a time before the explosion in social media and mobile telephony. The authorities could agree to commission regular and comprehensive prevalence studies so that risk factors and trends can be identified.

The emphasis needs to be kept on quality and not necessarily on quantity. Seeing children quickly for assessment (which is a potentially easy target to hit) might risk losing focus on keeping the concentration on maintaining robust care for existing patients and achieving good clinical outcomes for young people. Achieving more assessments could look good politically but there is a danger that such an emphasis might impact on existing services given the crisis of current resourcing in mental health services.

Mental health staff need to be motivated to achieve good clinical outcomes and this should involve all members of multi-disciplinary teams from caterers and cleaners on wards to consultant psychiatrists. The patient journey requires a complete joined up approach. Pay is just part of that motivation but also staff satisfaction levels, monitoring stress levels and effective workload management. Expanding clinical services has to be balanced with the stark reality that pay takes up about 62% of all spend within the NHS. Perhaps everybody in the NHS, not just the paymasters in government, need to prove that safety and quality are paramount within the NHS and that means every surgery, ward, operating theatre and clinical team being committed to driving up outcome service levels.

See also

The real scandal of psychiatric waiting times


The treatment of OCD and BDD in the NHS


I have always thought that we are all a little obsessive and compulsive to a greater or lesser extent whether it is the checking and rechecking we do in our every day lives or the occasional intrusive thought that cause us anxiety.  However, for some people the incidence of obsessive-compulsive disorder (OCD) can destroy their lives and those of their families.

This week I had the pleasure of attending a ward round at the National OCD/BDD Service, which is affiliated with St Georges University of London.  The service is a nationally and internationally renowned treatment centre dealing with severe, complex and resistant OCD and body dysmorphic disorder (BDD).

The National Commissioning Group for Highly Specialist Services (NCGHSS) of the Department of Health has commissioned a service for the treatment refractory Obsessive Compulsive Disorder (OCD) or Body Dysmorphic Disorder (BDD). The funding for such patients is by the Department of Health. Patients who do not meet such criteria can still be referred by the normal process and funded by their PCTs.

Patients will need to fulfil treatment refractory criteria: Have a Yale Brown Obsessive Compulsive Scale (YBOCS) score of 30 or more.  Unsatisfactory response to previous therapy in primary and secondary care or a specialist regional service (where available). Recommended treatments are an offer of either pharmacotherapy and/or cognitive behaviour therapy according to patient choice. In-patients are required to fulfil the criteria for admission and in some cases may not fulfil all the treatment refractory criteria (e.g. if there is a risk to life or severe self-neglect but has had not yet had two courses of CBT as an out-patient).  See the full criteria here.

The service combines behavioural and cognitive methods with state-of-the art psychopharmacological and other treatments where necessary. The service liaises closely with specialists who work in the neurobiology and psychopharmacology of these disorders as well as with psychotherapists of various schools.

Each patient is fully assessed and has an individualised treatment programme. Progress is constantly monitored using questionnaires of known reliability and validity. Thus, any treatment which is not effective is discovered early and the reasons why this is the case are examined and treatment changed or modified.

From what I understood the service does not use talking treatments much at all. CBT, so often the standard bearer talking therapy intervention in the NHS, is not considered effective with this group unless it is used in a very targeted way. The mainstay of treatment is Exposure and Response Prevention (ERP) repeated three times a day. ERP is a way to stop compulsive behaviours and anxieties from strengthening each other. Patients may have had a whole range of therapies before presenting at this specialist centre.  For most ERP is what is needed in the form of the reliable regular three times a day course of treatment.

In ERP treatment, patients learn to resist the compulsion to perform rituals. The recovery targets are eventually to stop engaging in these behaviours. Before starting ERP treatment, patients make a list, or what is termed a “hierarchy” of situations that provoke obsessional fears. For example, a person with fears of contamination might create a list of obsessional cues that looks like this: touching garbage, using the toilet and shaking hands.

Are you affected by any of these issues?  Please refer to the resource links below or speak to your GP.


The Centre for Anxiety Disorders and Trauma provides a national OCD/BDD service
Leaflets on OCD from the Royal College of Psychiatrists
OCD: A web guide for health professionals Contains useful links
Summary of NICE-recommended treatment approach for OCD Stepped care model for treatment of OCD
NICE Guideline: Obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) (CG31)



Therapy in the NHS

I have been continuing with my placement in an NHS Mental Health Trust and it seems that with every visit I learn something new.  I had been familiar with Cognitive Behavioural Therapy (CBT) before the start of my placement through my lectures and my own prior knowledge. However, this week I attended a team meeting in a sexual behaviour unit in a forensics unit and learned about the Dialectical behaviour therapy treatment programme.

Dialectical behaviour therapy (DBT), a cognitive behavioural therapy, was developed by Marsha Linehan, PhD, at the University of Washington, and is a type of psychotherapy (sometimes called “talking therapy”) for borderline personality disorder (BPD). Of course I get reminded that in psychiatry one is often dealing with the treatment of sometimes severe mental illnesses.  In psychotherapy, especially private practice, one is less likely to encounter clients with the onset of such illnesses. Mentalization-based treatment (MBT) is a type of psychotherapy created to treat people with borderline personality disorder. Reflecting back group psychotherapy is also a new concept to me. However, it is apt that I am about to start group process work on my course when compulsory attendance is required for the  duration of the work.

I am often asked why I don’t offer a critique of these models in my blog posts.  However, whilst I might have some preliminary thoughts and views, I need to gain exposure of how these models work in practice before I can comment on the effectiveness of these models. One thing for sure is that awareness of more treatment models is helpful for devising short term treatment models for my new placement in a counselling centre in West London which offers clients 6 sessions, in the first instance.  This will be a great  opportunity to blend theory with practical application.

My NHS placement also offers invaluable insight into how treatments such as ECT and pharmacological treatment work for depressed patients.    More about this in future posts …..

Psychotherapy in the NHS
Borderline Personality Disorder (BPD)
Eating Disorders


It is intriguing how some patients can invoke certain feelings and not others.

It was good to get back to my psychiatric placement at an NHS Mental Health Trust today and to a ward review meeting.  I have been sitting in on clinic sessions at a university hospital with consultant psychiatrists covering new assessments, outpatient follow up appointments as well as team meetings discussing the management of care. It was two weeks since I was last at this ward review and it was heartening to notice the visible improvement in some patients in the intervening period.

There were a couple of patients who had regressed and this was producing some feelings in me (what is called counter transference). One patient, a middle aged man suffering with severe depression, was continuing to present with anxiety and helplessness.   I felt like wanting to hug him.  However, his depression is so severe that he has been prescribed a course of ECT. It is intriguing how some patients can invoke certain feelings and not others. Perhaps counter transference is when our own stuff and issues have been triggered and when we identify with the personal circumstances. I was particularly taken by the love and support of his partner (who was present in the session) and who appeared to be a rock of support in spite of very challenging circumstances.  The experience made me aware of the vital role that carer groups undertake in the management of support networks for families and friends of those suffering from mental illness.

Related posts. 
The 1-1 relationship between psychiatrist and patient
The importance of challenge in the therapeutic relationship 
Transference and counter transference
Resistance in therapy
Dr Marie Keenan interview


Paranoid schizophrenia – not that dissimilar in some ways to high blood pressure or diabetes

I have been enjoying my psychiatric observational placement and have had a rich environment in which to observe an NHS mental health care setting. I have been shadowing the consultant psychiatrist in outpatient clinics and in (locked) ward rounds as well as attending team meetings of a community mental health team (CMHT). I have also attended a Mental Health Act Tribunal meeting as an observer and that was an added bonus to my training. The whole experience has given me great insight into the care plans of patients suffering with various mental illnesses as well as to the current legislative and legal environment surrounding hospital care. 

It was baffling at times when I started as all I was hearing was abbreviated terms that I did not understand.  For instance, terms such as CPA (Care Programme Approach),  CTO (Community Treatment Order), IAPT (the Improving Access to Psychological Therapies), DNA (did not attend), AMHP (Approved Mental Health Professional) were banded around at will and often I felt like asking people to slow down. However, finding out how the NHS practices work has been an interesting learning curve as well as understanding the role of patient care co-ordinators. 

.As I said in a previous post the 1-1 session between psychiatrist and patient is essentially a business like arrangement where discussion centres on how to agree a treatment plan.   

Spotting the symptoms of these illnesses will be a critical part of the placement for me and will be an on-going process.  I am also intrigued about the formulation of care treatment plans. In depressed patients medication is prescribed but often with CBT sessions.  With “paranoid schizophrenia” CBT sessions can be a part of treatment but there is more evident symptoms of psychosis. It seems that the  more patients understand about their condition the more they will realise and appreciate the need to take long term medication. Consultant psychiatrists describe their illness as not being that dissimilar in some ways to high blood pressure or diabetes in that it needs regular and long term medication to remain healthy and help keep the symptoms away. The care plan will outline the relapse symptoms so that the wider healthcare team can be enpowered to spot signs of relapse.

I have wondered what it would have been like for people suffering from mental illness in times past when anti psychosis medicine was not around and when there was a very different societal attitude to mental illness. Some hospitals indeed would have had up to 4 times the number of in patients as recently as 50 years ago. My own intrigue about nature vs. nurture and the cause of mental illness diagnosis – whether it is due to genetic issues, personality disorder or psychosis –  will continue.

More soon.

 Related post
The 1-1 session between patient and psychiatrist