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Dr Niall Muldoon We need radical and brave leadership to turn around child mental health services

The Ombudsman for Children says it is now clear that we’ve reached the end of the line with the current CAMHS service.

IN 1966 A first-time Minister with no cabinet approval announced the introduction of free education in Ireland. Donogh O’Malley’s brave move changed Ireland’s destiny by providing opportunities for children who would never have had the means to complete school. In turn, he provided Ireland with the opportunity to reach its potential as a global player economically with a highly skilled labour force.

Brave thinking of this kind is needed again to address what is an absolutely failed Child and Adolescent Mental Health Service. In much the same way that Donogh O’Malley’s bold move benefited both children and Ireland as a nation, real leadership now can create a new mental health service that will not only save children’s lives but also help them to contribute to the country as a healthy adult.

This week the Mental Health Commission Independent Review told us that they cannot provide an assurance to all parents in Ireland that their children have access to a safe, effective and evidence-based mental health service. If these children are not safe, then they are at risk.

Draw a line

Adjustments or adaptations will not cut it when it comes to the problems that currently exist with our Child and Adolescent Mental Health Services (CAMHS). The Mental Health Commission Independent Review has recommended the immediate regulation of CAMHS and the creation of a comprehensive strategy, and even these strong recommendations may not be enough.

What is needed is a totally new vision and a new approach. 

A radical and brave mental health service for children will widen the professional leadership. The current model of care places the onus on the consultant psychiatrist and all clinical responsibility rests with them. In international practice, this is considered an outdated model and most countries have moved toward a more multi-disciplinary leadership approach. It is also unsustainable with the current limited medical workforce.

A radical and brave mental health service for children will investigate and address professional misconduct when doctors who prescribe the wrong drugs for children, or who put a child on repeat medication and do not follow up to review, are falling below acceptable standards. They should be referred to the Medical Council and other professionals who fall below acceptable professional standards should also be held to account. That is how we can begin to rebuild trust with the children, parents and carers who rely on this service.

A new approach

A radical and brave mental health service for children will fully commit to governance and oversight. The Mental Health Commission report details governance and oversight failures at the highest level of the HSE. It outlines cases where children were at risk of harm, where one CAMHS area accepted only 38% of referrals, where 140 children were ‘lost to follow up’ and where none of this was uncovered by the HSE itself.

A radical and brave mental health service for children will ensure that all children in all areas receive the same service. It will ensure all staff are doing the same thing when faced with the same situations or problems. It will follow the same referral criteria and guarantee the same quality of care.

That is not the case at present as there are 73 teams with different leaders and different ways of carrying out their business.

A radical and brave mental health service for children will widen the therapeutic framework to include their family and environment. Many CAMHS teams have carried out outreach work in schools and homes to better provide for the child in their care. This work should be developed and expanded. When a CAMHS team recognises the context of a child’s life and engages with their environment (parents, siblings, friends) then they are more likely to improve the outcome for that child.

As a psychologist, I am fully aware of the range of difficulties children suffer with their mental health and I know that early intervention is the best way to ensure a healthy adult. Having worked with many children and families directly affected by sexual abuse, I have seen the powerful impact of a consistent, safe and well-trained service to those children, both in specialised services and in Primary Care.

However, successive governments have failed to build up the Primary Care element of services for children with mental health difficulties. There is evidence of silos existing in the provision of children’s mental health services with too many barriers blocking the operation of a holistic service based on the need of the specific child. The report specifically highlights the needs of vulnerable children such as Travellers, LGBTI+, Intellectual Disability and Refugees.

Children first

Children deserve a child-centred, evidence-based, safe and consistent CAMHS service. This report says there has been a breach of children’s right to the highest attainable standard of mental health. Long waiting lists, lack of appropriate therapeutic interventions, “lost” cases and difficulties in primary care and disability services are all evidence of this breach. Little to no progress has been made in remedying this.

In 2022 only 5.2% of the overall health budget of €20bn was spent on Mental Health (both adults and children). This is significantly below the 10% previously recommended by Slaintecare, and the World Health Organisation (WHO) recommended 12%. It is also a decrease from 2021 when 5.6% of the overall health budget had been allocated to mental health. However, the real issue is that the HSE does not know how much they actually spend on children’s mental health in Ireland. The only figure we have certainty on is that, in 2022, they spent €137m on CAMHS, which is significantly less than 1% of the overall health budget.

We have reached the end of the line with the current CAMHS service. Small changes will not generate the improvements that are needed. A radical and brave reimagining of our mental health services for children is what is needed. I would urge Health Minister Stephen Donnelly to look to Donogh O’Malley and commit to that brave step. This is what our children deserve.

Dr Niall Muldoon is Ireland’s Ombudsman for Children.


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