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.