A national disgrace: NHS fails to treat child mental health

A whole generation of children is being failed by mental health services, say GPs who struggle to access specialist help for their patients.

GPs are finding their referrals increasingly batted back, with three in five of those made to specialist child and adolescent mental health services (CAMHS) resulting in no treatment at all.

GPs report that local trusts are raising thresholds for care, with some only accepting patients who have attempted suicide or are experiencing symptoms of very serious mental illness. Cuts to mental health funding mean services have struggled to cope with a 40% increase in GP referrals since 2012. This has meant that young patients are being directed to local charities or school counsellors rather than receiving specialist care.

And this is all occurring as rates of suicide rise in the UK; it is now the leading cause of death among men aged 20 to 34 years.

The Government insists it is ploughing more investment into CAMHS but experts say it may be too little, too late to address a crisis that is causing significant suffering and storing up major problems for the future.

Crude criteria

A Pulse Freedom of Information request to 15 mental health trusts in England reveals that 61% of referrals are not treated, up from 56% in 2012, with the figure as high as 80% in some areas. More than a third of children referred are not even assessed, the investigation found.

The proportion of GP referrals assessed in 2015 was 64% – down from a high of 89% in 2013.

Seven out of the 15 trusts showed marked reductions. For example, at Leeds and York Partnership NHS Foundation Trust the proportion treated fell from 42% to 26%, and at Norfolk and Suffolk NHS Foundation Trust it fell from 46% to 20%.

The figures suggest the care of children with mental health problems is much worse than experts had thought. A report last year by the children’s charity NSPCC found that four out of five children referred to child mental health services – including those referred by other professionals as well as GPs – were being treated.

But GPs tell Pulse that crude thresholds applied to the CAMHS referrals criteria are excluding many of those they refer.

Alarmingly, these criteria include only accepting referrals when patients have previously attempted or are at risk of suicide, are experiencing psychotic symptoms or are self-harming. Examples include:

• A GP in the South-West saying patients in his area ‘have to be suffering from psychosis or a serious suicide attempt before CAMHS will see them… Self-harming is not a criteria they accept – it is “dealt” with by the school nurse’.
• A GP in the North-West saying patients ‘must be actively suicidal’ to get help.
• A Midlands GP saying a referral must be for a ‘severe’ mental health problem such as ‘suicide attempts or hallucinations; very little else is seen’.

Dr Dominique Thompson, a GP in Bristol with special expertise in young people’s mental health, says the findings show the system is ‘failing the next generation’.

She says: ‘We risk our CAMHS becoming a source of national shame if they continue to be so poorly resourced.’

Other GPs also highlight worrying cases where they are concerned about potential harm not only to the child themselves but to others – but still cannot get CAMHS to treat them.

Dr Karen Cox, a GP in Bristol, says: ‘Recently all referrals seem to get bounced. They’ve included children who self-harm, a child who was physically abusing his mother and a child with severe night terrors after the loss of his father. All of them were advised to contact local charitable organisations.’

Experts say the refusal of referrals is distressing for GPs as well as damaging for their patients.

Dr Faraz Mughal, RCGP clinical fellow for young people’s mental health and a GP in Solihull, says: ‘GPs are at the frontline of the NHS and treat so many young people with mental illness, and are trained to identify their needs. If they think further expert input is required then GPs really need to be supported in that.’

And having patients bounced back puts even more pressure on already overburdened GP practices.

Dr Mughal says: ‘It puts GPs in a difficult situation because often they are the person who knows the child and the family best; it leaves them having to try to manage it themselves where those resources just are not available.’

Despite government promises of ‘parity of esteem’ between physical and mental health, all this is happening against a background of significant cuts to the mental health budget. In April 2014 Pulse revealed most CCGs were applying 20% larger cuts to CAMHS than to other healthcare services.

Increasingly vulnerable

Between 2013/14 and 2014/15, referral rates to CAMHS increased five times faster than the service’s workforce.

The Government-commissioned Mental Health Taskforce report in February said one in 10 appointments had been cancelled due to staff shortages, while specialist CAMHS were being run by ‘junior staff who lack the requisite skills and too few therapists with the necessary training’.

And it comes at a time when experts believe children are increasingly vulnerable to stress and mental health problems from societal pressures, with a House of Commons health committee inquiry highlighting the growing issue of ‘cyber bullying’ and an increasing focus among young people on celebrity status. These effects have been compounded by economic austerity and intense competition for future employment.

There are slight signs of improvement, however. The Government’s taskforce on children’s mental health and well-being has pledged to get rid of the ‘tier’ system for referrals, so ‘there are more support structures that the children and family can access straightaway, to provide more community support’, says Dr Mughal.

Progress has also been made to incorporate Improving Access to Psychological Therapies (IAPT) into children’s mental health services, with an audit early in 2015 showing services employing IAPT had reduced assessment waiting times by 60%. And the GP Forward View commits the NHS in England to providing access to mental health workers for every GP practice – though there is little detail of how this will be funded.

In Scotland, the executive has promised an additional £150m for mental health services and new ‘mental health workers’ in GP practices.

And the Scottish Government recently responded to the increased demands on CAMHS by committing to more school-based counsellors to help children access support when they need it.

NHS England chief executive Simon Stevens has acknowledged the need for change. He told the NHS Confederation conference last month CAMHS was the ‘most creaking’ part of the NHS mental health sector. A Department of Health spokesperson says: ‘No child who needs help should be refused it. That is why we have introduced the first-ever mental health access and waiting time standards and are putting in a record £1.4bn to transform support for young people.

‘This investment is just beginning, so will be making an increasing difference in the years ahead – every area in the country has produced plans on how they are going to work together to make sure young people get support before they reach a crisis point.’

But some are sceptical about whether the money will materialise. Dr Phil Moore, a GP in west London and chair of the NHS Clinical Commissioners’ Mental Health Commissioners Network, says the funding must be ringfenced because ‘despite our commitment to better mental healthcare for young people, it has to be acknowledged that CCGs are dealing with a myriad of competing demands on budgets’.

Without such guaranteed funding, the overall picture will continue to be one of a system failing the most vulnerable in society.