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


Will additional funding for talking therapies in the NHS work?

This week the Government announced extra funding for talking therapies in the NHS, crisis care, as well as a focus on preventing illness and proposals to strengthen early intervention and to integrate mental health services into primary care.

The austerity agenda over the last 7 years has severely impacted the budgets of mental health services and affected frontline services, so the news of additional funding was met with a bit of a fanfare in the news outlets. We know that not being able to access services invariably intensifies feelings of isolation, desperation, a sense of worthlessness and depression. Rejection can be routinely experienced in a personal way when patients can perceive there is something wrong with them when they can’t secure an appointment.

The unfortunate reality of access to talking therapy is that only about 16-17% of adults who need therapy are currently able to get it on the NHS. The additional funding, whilst very welcome, will only seek to increase this to 25% by 2020/21 (for children it will be 35%).

I would argue that quality means having enough therapists within the service to provide enough sessions and it means a choice of therapies for patients. Historically the NHS and NICE guidelines has been almost fixated on the CBT approach given their medical model of therapy services and their quest for an evidence base. This one size fits all approach does not, in my opinion, meet the diverse needs of patients.  There is other evidence to suggest that the relationship and the therapeutic alliance is what heals, not manualised scripts. Improving quality means employing therapists trained to deal with the complexity of cases they face. Access and quality must, therefore, go hand in hand and waiting times need to be addressed.

I made these points on Sky News on Monday when interviewed with Dr Marc Bush of YoungMinds.

Parity of esteem between physical and mental health services is a laudable ambition that hasn’t been followed through in practice. Take the level of research funding, for example. Approximately £8 is invested in research per person affected by mental illness. To evaluate this rate of investment it is worth noting that 22 times more is spent on research into cancer, and 14 times more on dementia.

Mental health services in the NHS are being pressured by rising demand, historical underfunding, staff shortages, poor staff morale and the failure of funding to reach the frontline. Public health promotion campaigns, such as the Heads Together campaign, can do commendable work but they can also have the effect of increasing the pressure on existing resources by boosting demand.

The devil will be in the detail of how the extra funding is allocated and whether the additional funding makes the NHS more attractive as a potential employer for therapists. Delivering these new integrated services within primary care is critical to building care holistically around the needs of the person to improve their health outcomes and support them to achieve wellbeing.

What we might need to acknowledge is that whilst additional funding for mental health services is to be welcomed a lot of mental anguish might be inseparable from far deeper and wide ranging problems such as social fragmentation, poor housing, trauma, unstable employment and discrimination.

See also

We need to talk coalition 


The Blue Whale game is not as risky as we may fear

Today I was interviewed on Sky News about the risks posed by the Blue Whale game in the UK and about peer pressure facing teenagers. Blue Whale is an online game that originated in Russia and where it is claimed users are manipulated into self harming and ultimately encouraged to commit suicide.  This has led some to refer to it as the suicide game. It is feared that up to 130 deaths in Russia are linked to the phenomenon. Also referred to as the “Blue Whale Challenge”, it encourages users to complete a series of tasks over a 50 day period. There are fears that the game’s contagion could spread to the UK with police and teaching bodies issuing warnings about the risks posed by the game.

Whilst not wanting to minimise the danger or to downplay the potential risks I would caution against getting too worried.  The UK is not Russia. There is an absence of social mobility and economic opportunity amongst young Russians (particularly for those outside of elite circles) growing up in a post communist society, and perhaps living in a high rise block from the Soviet era in a grim part of middle Russia. British teenagers do not face anything as dismal in their lives. The suicide rate in Russia is high and Unicef reported in 2011 that the country has the third-highest teen suicide rate in the world. We can’t even be certain that the game actually caused the deaths or that these deaths would have occurred in the absence of the game.

The trouble with setting boundaries around technology more generally is that parents have knowledge of pre internet behaviour. Young people don’t have a baseline behaviour of something other than the internet, its as if it has always been here. Engagement with the internet is not optional for them. For them the internet and specifically social media engagement satisfies prime drives for survival and to affiliate. However, we wouldn’t allow children to go to a public park unsupervised but some teenagers are given unsupervised access to a smartphone, which is essentially a portal to the outside world with high potential for encountering inappropriate material. Most, however, will be fine and will have developed sufficient levels of resilience to cope with cyber bullying or inappropriate suggestibility from others.  But just like with alcohol and food there will be a small proportion who will develop problem behaviour with technology and will be susceptible to manipulation.

Some people might wonder how someone could fall under the spell of something so ridiculous as following the commands of strangers to commit actual self harm. Indeed, others would say that all you need to do is switch off the computer if being bullied online.  This is a little simplistic. The teenagers who are selected for cyber bullying are often vulnerable and are, therefore, at greater risk of being manipulated and exploited. Teenagers often worry about their appearance, their weight and whether they are cool and so can be vulnerable to being bullied. They often seek approval from others to satisfy their feelings of esteem. Children who suffered disorganised attachment whilst growing up are particularly vulnerable to exploitation.

The sinister aspect to the Blue Whale game is that other teenagers are also recruited by the gang leaders to select and recruit the most vulnerable users, called masterminders. The kids who create the peer pressure are often frightened and lost themselves and they seek strength in groups. We see this quite commonly as a feature of teenage gang violence in our cities. The even more sinister aspect is that some of the Russian gang leaders behind the game, and who referred to getting rid of ‘biological waste’, received love letters from teenagers after being locked up.

Whilst I have downplayed the risks associated with the Blue Whale game in the UK I would, nevertheless, suggest that parents remain vigilant about the risks presented by this and other online games. They can become more proactive in the active monitoring of their children’s web usage. Parents should keep lines of communication open with their children as they will need someone, who they can trust,  to turn to if they encounter any problems online, or in the real world for that matter. The key is to try to help them achieve a balanced level of engagement with technology and to ensure that their activity takes place within a safe environment. They can learn to say no and to only share information and content that they are comfortable with. Try to agree terms and conditions with your child around appropriate device time and above all don’t allow devices in their bedroom.

See also

NSPCCStaying safe online
Childline – Call them free on 0800 1111 or get in touch online. 
See also some related articles:
Do you have a problem overusing your smartphone
Digital detox from smartphone addiction
How to digitally detox and stay connected 

For anyone affected by the issues in this article, you can contact the Samaritans in the UK or call 116 123. Calls are free.


Are fidget spinners a useful learning tool?

Have you heard of fidget spinners?  If not, you might be surprised to hear then that they top the lists of the best-selling toys on Amazon UK.  They are the latest craze amongst school children and are being hailed as a learning tool to help kids suffering from inattentive states of mind.

Today I was interviewed on Sky News about the latest craze of fidget spinners and the potential benefits for kids using the devices. See the link to the interview here The central issue, it seems to me,  is whether these devices can be effective stress management tools in addition to being an aid to learning for kids suffering with the negative aspects of attention deficit hyperactivity disorder (ADHD), or whether they are distracting and could cause problematical behaviour in themselves.

The marketers claim that the devices can be an aid to learning for those suffering from ADHD in the classroom as well as potentially relieving the symptoms of ADHD itself, autism and even post-traumatic stress disorder (PTSD). These are big claims.

However, there are no clinical research findings to support these views, at this stage of their usage. At best what could be said is that there might be anecdotal evidence to suggest that these devices may help inattentive kids to concentrate on their learning. However, it would be inaccurate to suggest that these devices support the learning capacity of such kids, particularly those suffering with symptoms associated with ADHD.

These spinner devices are visually distracting which could be their major drawback. Some of the devices have lights on them which could make them further distracting in addition to the whirr sounds. This could potentially act as a mitigating factor against their usefulness as a learning tool. Other fidget devices, which don’t have the visual distractions, could possibly be better gadgets as an aid to learning for kids suffering from inattention. Indeed, good old stress balls (with no visual distractions) would be more effective as an aid to learning for inattentive kids.

Riding a stationary bike whist reading would offer the potential for small and non-distracting motor movements. Fidget Spinners,however, don’t require gross body movement, which is needed for increasing the activity of the frontal and prefrontal parts of the brain that are responsible for sustaining attention.

Problem behaviour, as with any dependence on any gadget, is when negative consequences begin to occur in other aspects of the user’s life or when they act as barriers to communication.  Addiction is the search for emotional satisfaction. It is worth asking what happens to the emotional regulation and mood when the device is not available. The key is that kids are taught how to use these devices appropriately so that they do not prove to be distracting to their learning but can be used in a constructive way.

If you are a parent and worried about your child potentially having ADHD it could be worth a consultation with your GP who will be able to direct you to the appropriate support services. See the NICE guidelines for more information on support for ADHD.

See also

My son is addicted to computer games