by Dr Duncan Law
I have spent all of my professional life working with others to try and improve the quality of Children and Young People’s Mental Health (CYPMH) services – so why am I left so concerned by the recent leaks from the Green Paper?
Setting up the Child Outcomes Research Consortium (CORC), developing and implementing the Choice and Partnership Approach (CAPA), the development of the Goal-Based Outcome (GBO) tool, and my more recent involvement in CYP IAPT, have all had a focus on quality improvement at their core. Alongside these, I have fought to influence the CYPMH system to concentrate effort and funding, on applying sound psychological research and practice to issues of prevention and early intervention in mental health (and not just focus on the equally important, headline grabbing, crisis end of services). With both these interests in mind I was looking forward to the publication of the CYPMH Green Paper with expectations that it would deliver on quality, early intervention and prevention, but the recent leaks of some of the content of the Green Paper have left me worried.
At the centre of the leak was that there would be new waiting time guarantees, of no more than four weeks, for any child presenting with anxiety or depression. Now this might seem puzzling as to why this would worry anyone? Let me be perfectly clear, in and of itself, the idea of improved access and waiting times is not a problem – in fact they are to be celebrated. For so many years children and young people have had to wait too long to receive appropriate help – even the current waiting time targets of 12 weeks are too long for most young people and their families struggling with the impact of mental health issues. We have to take a wider view of the reasons behind the problem of long waits to see where my concerns arise: current long waits for help are almost entirely a symptom of lack of resource in the CYPMH system. Best estimates suggest that services are currently resourced to see only about 25% of children diagnosable mental health problem and even the welcome £1.4billion injection of cash in to the system will only resource it to see 35%. This is a woefully inadequate level of funding for the biggest health issue facing young people in the UK today. It is this lack of funding that leads to a lack of speed of response in services. A new target will not solve this issue.
The second issue is one of measurement. Having spent a good 15 years thinking seriously about the best ways to measure the impact of CYPMH services on the lives of children and young people I have learnt that what we choose to measure and how we choose to evaluate services, will impact on how services are organised and where limited resources are deployed. And here is the rub: if we evaluate services only on the speed at which they see children they will move resource to see children quickly. This is fine until we think what we lose by shifting this focus – my fear is that by seeing children quickly (which is an easily target to hit) we will lose focus on the more important (and frankly more difficult) issue of providing services that have real positive impact on the lives of children: quality!
Quality causes the system real problems: it is both difficult to achieve and it is nearly as difficult to measure. Waiting times, by comparison, are easy to measure. Why do we need to find something to measure services on? Well it gets back to the money issue – we have just received one of the biggest cash injections into child mental health ever – it is imperative that we have something to show for that extra cash if we want to see even a penny more. Sadly, we have collectively failed to gather good quality data on clinical outcomes to demonstrate the real quality of child mental health services. And so, we are cornered in to measure something that will be a very poor proxy for anything like the quality of the excellent services we believe services can and do deliver.
If the leak is to be believed we are taking a big, backward step to measuring quantity at the expense of measuring quality – I hope the leak is wrong or at least partial. The Green Paper’s publication has already been delayed – I hope it is delayed further to get the balance of quantity and quality right – otherwise we will be back to hitting the target but missing the point.
