A crisis in children's mental health? How is Wiltshire coping? Part One: the system is changing
A three part series on the treatment of children and young people's mental health problems - in Wiltshire and in the Marlborough area.
There is a growing awareness that child and adolescents' mental health is posing a problem of crisis proportions for health services and schools. Most importantly, as answers are being found, the children and young people themselves are being asked their views on the services and suggesting improvements.
Healthwatch Wiltshire, the independent organisation speaking for local people on health and care, has published a report on young people's views and worries.
They trained a number of young people to be Young Listeners - and hear first hand and without adult interventions (interference?) about children and young people's experience of Wiltshire's health and social care services.
When it came to mental health there were three clear areas of concern: lengthy waiting times for treatment, the problems when young people had to 'transition' to adult mental health care, and the need for continuity of care.
A student survey at St John's Academy highlighted ways to improve how early signs of mental health worries can better be treated - see Part Three of this series.
Other views have come from the recent Wiltshire Youth Summit on health and police issues (with representatives from all the county's secondary schools), from Wiltshire's Children in Care Council, from local user participation groups, from the Wiltshire Assembly of Youth, Wiltshire Council's Health and Wellbeing Pupil Survey and Council-led participation in workshops and surveys.
NHS figures show that nationally the number of children and young people with mental health problems attending A&E has increased over the past four years by 89 per cent. Even if that rise was from a relatively low base, it is an alarming statistic. Childline has seen calls about mental health issues rise by 36 per cent over the last four years.
Half of all mental health problems in adults start before the age of fifteen and three quarters before the age of eighteen. As one health professional told me, intervention when mental health problems first arise makes not only ethical, but economic sense.
After years and years as a fairly neglected or somewhat hidden part of the NHS, mental health services for young people are coming steadily closer to the top of the agenda. The Prime Minister has made it clear that young people's mental health is now a priority.
Young people's mental health services go by the NHS acronym of CAMHS - pronounced 'cams' and standing for Child and Adolescent Mental Health Services. And the latest figures show that nearly 3,000 children and young people were treated by CAMHS in Wiltshire in 2015-2016.
The lead commissioner for child and teenage mental health who works for Wiltshire Council and NHS Wiltshire told me: "Investment in CAMHS hasn't really kept up with demand - this is now being addressed."
NHS England has provided more funding. Funds available for Wiltshire's services increased from £5.7million in 2014-15 to £7million in 2016-17 - with increases continuing until 2020-21. The more CAMHS are improved - or 'transformed' - the more funding comes from NHS England in the form of transformation bonuses.
At present CAMH services for Wiltshire are provided by Oxford Health NHS Foundation Trust - available for 0-18 year olds who are referred by their GP, health visitor, school or hospital doctor. Several charities also work in this area - for instance Relate provides community and school based counselling.
However the two main tiers of the CAMHS are paid for and overseen by different organisations. The primary tier - catering for mild to moderate conditions - comes under Wiltshire Council and has about ten staff. There are also seven consultants providing emotional wellbeing support.
The specialist tier - catering for more severe cases - comes under Wiltshire Clinical Commissioning Group (so is from the NHS budget) and has about 66 staff.
Oxford Health have a CAMHS unit at Savernake Hospital as well as the eating disorders unit there. Another tier up, Oxford Health also run the 12-bed facility in Swindon - confusingly called Marlborough House - for in-patients from much of Wiltshire and Swindon.
This current organisational structure is described in a Wiltshire Council/CCG document as providing a 'patchy and incoherent service' and it is stretched: "Parts of the local CAMHS system are almost at gridlock with increasing pressure on GPs, primary and specialist CAMHS and A&E departments."
There are still problems with spotting young people's mental health problems and in dealing with them.
Emily Palmer - who has had first hand experience of CAMHS and wrote Scrambled Heads - A Children's Guide to Mental Health - did a straw poll of teachers via the internet. Ninety per cent said they had had no training in mental health and did not feel able or competent to help a student.
She says teachers often do not want to interfere - feeling they may be 'crying wolf'. When some teachers spot signs of anxiety or worse "There's a dilemma between breaking trust with students versus the duty of care - so they tend to avoid conversations about issues."
And a leading eating disorder charity (Beat) claims that nationally GPs are routinely failing to provide adequate care for patients - with just one in three referred for specialist assistance. Of 1,267 people questioned who had sought help for an eating disorder from their GP, 34 per cent said they did not think their doctor knew how to treat them.
Moves to provide a fit for purpose CAMH service in Wiltshire have already brought significant improvements. And next year there will be a step change in the service with a new contract for a single provider across all CAMHS services - to answer the challenge of turning CAMHS into a whole system rather than a series of providers.
Like commissioners across England, Wiltshire Council and the CCG will be under 'significant' scrutiny to make sure all the new money designated for improving CAMHS is really getting to the font line. It is there it is so badly needed to help children and young people ward off the mental health problems to which they are prone.
A recent letter from NHS leaders warning that local NHS bodies must meet the 'acid test' and prove where the money is going, shows they are worried new cash for mental health may not be properly used. They are demanding accountability and transparency for mental health spending.
Part Two will be online soon: Transforming CAMHS services for Wiltshire
CASEBOOK ONE: Names have been changed throughout these accounts of CAMHS at work
We will call her Anne. One of her two children - who we'll call Jill - is now sixteen. At primary school Jill was very disruptive, but at secondary she appeared to have calmed down. Then one day at school, when she was twelve, she tried to hang herself - and was automatically referred by the school to CAMHS.
"CAMHS", Anne says firmly, "were good." Her daughter was seen quite quickly. She was prescribed talking therapies. Then there was a gap while a new therapist was employed - and during that time she tried to kill herself again.
Although she got a bit better, Anne says: "Talking therapies were not really successful for her." She was discharged after five months.
Anxiety about school work and the pressures of school exams got the better of her again. They tried more talking therapy. It did not work. So she saw a psychiatrist who put her on medication and she is still on it. She has recently had another 'lot' added to her dosage: "And that seems to work".
Anne told me: "CAMHS were wonderful." They worked with the school to find ways to make things easier for Jill. And Anne has meetings at the school every six weeks.
Jill sat her GCSEs: "She didn't get the grades they'd predicted - ABs. But she got good grades - BCs. Better than we hoped. We were quite impressed because we didn't think she'd make it to the exams."
Now in the sixth form, she is finding the going very tough. She is getting a lot of support - a teaching assistant, who has a long experience in this area, sees her three times a week. "There's been no talk of suicide for the last two months - and her panic attacks have calmed down."
Anne stresses the help given by her other child, who is two years younger than Jill, has been "Fantastic - he's been brilliant with her. The times she won't talk to me, she'll talk to him." He has had help from his school and been supported by Young Carers Wiltshire.
Anne is very positive about the changes coming to CAMHS. She is especially hopeful that parents will be able to refer children to CAMHS - up to now referrals are mainly by a GP or teachers. And she favours self-referral too. She wants more schools to sign-up to having CAMHS staff on the premises.