In June this year, 73 clinical psychologists, teachers, social workers, parents and others signed an open letter to the Cabinet Secretary for Health and Social Services, Vaughan Gething AM, asking him to support the recommendations made in the Children, Young People and Education Committeeâ€™s report, Mind over Matter. The report provides an ambitious and exciting template for reform of Child and Adolescent Mental Health Services (CAMHS) in Wales.
The report called for a whole-school approach to wellbeing, which would not only benefit pupils but teachers too, and would mean schools could move away from the current â€˜exam factoryâ€™ mentality. It also called for a genuine and properly resourced multi-agency approach to addressing wellbeing issues, whilst also highlighting the current gaps in service provision. It even outlined how to address the gap between third sector and specialist care, referred to as the â€˜missing middleâ€™. So when the Cabinet Secretaryâ€™s reply came and rejected many of the reportâ€™s recommendations, understandably there was deep disappointment from those who had called for action.
CAMHS is under more pressure than ever before. In the years 2010-2014, there was a 100% increase in demand. Young people awaiting outpatient treatment in Wales (2,410) is double that of adults (1,291) and triple that of those in later life (682). Mental health problems account for the biggest increase in Welsh Government expenditure for the period 2017-18, and expenditure has increased over the last decade by 22%. This increase is predicted to continue; according to the World Health Organisation depression is set to become the biggest â€˜burden of diseaseâ€™ by 2025.
Whilst mental health spending has increased, spending on CAMHS has remained broadly consistent for the last decade. It accounts for just 6.8% of the Â£712 million spent on mental health in Wales. This is baffling when you consider that 50% of mental health difficulties present before the age of 14 and 75% before age 18. Why is it when so much evidence supports early intervention and prevention we continue to neglect children and young peopleâ€™s mental health? Effectively we are spending our precious and limited resources on firefighting many problems that should be being addressed way before adulthood. It is obviously time for a rethink and a step change in the approach being used.
The proposed step-change to CAMHS set out in the Mind over Matter report is a whole systems approach â€“ also known as the â€˜iceberg modelâ€™ â€“ because it is designed to address the â€˜hidden burdenâ€™ of mental health problems. This approach acknowledges that families with multiple Adverse Childhood Experiences (ACEs) and high levels of social adversity may struggle to access traditional services, especially in times of need. The changes would replace the current tiered model of service provision which relies on families having the practical and psychological resources to engage with clinical and specialist services. Often those in the most need do not have these skills.
The proposed changes would instead offer community-based family intervention services that allow professionals to engage with families in ways that account for these difficulties. It also means embedding additional services within or alongside existing third sector community-based provision and offering a joined up multi-agency approach. This means professionals will work in community-based services rather than being locked away in specialist provision (with long waiting lists).
In a tiered system people have to fight for a diagnosis and then, if they get a diagnosis, they must work their way up the tiered system in order to access support. This just makes no sense, especially at a time when people are vulnerable and in need. It is not efficient and it is not a prudent healthcare approach.
A whole-systems approach would ensure that practice that responds to trauma and attachment issues happens across the whole system â€“ right up to the â€˜frontlineâ€™. Crucially it would mean a network of professionals delivering evidence-based high quality care that would reduce the number of referrals to and therefore pressure on CAMHS.
These changes would allow referrals to be assessed based on observed levels of distress, rather than diagnostic labels. Many children and young people are currently excluded from services because they do not meet diagnostic criteria, such as those that present with challenging or self-harming behaviours but do not meet threshold criteria such as children registered as in need, in foster care, youth offending services, or homeless. Distress based approaches already implemented in Aneurin Bevan University Health Board (ABUHB) have demonstrated that as well as reducing waiting times, for every Â£1 spent Â£7 is saved.
Thankfully the Children Young People and Education Committee took a bold move at the plenary debate. The Chair of the Committee, Lynne Neagle AM, rejected the Cabinet Secretaryâ€™s response and asked for it to be revisited after summer recess. The Chairâ€™s moving speech was followed by impassioned cross party support for the Government to reconsider their position â€“ I urge you to watch this recording of her speech if you have not already. Together they called out the missed opportunity for thoughtful, innovative and prudent change.
If the Welsh Government is serious about tackling the rise in childrenâ€™s mental health problems and reducing the inequality gap then we need to see the creation of policy that allows services to prevent, not exacerbate, the problem. We definitely donâ€™t need more of the same.
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