Concerned over Green Paper leaks

Dr Duncan Law


Dr Duncan Law, Consultant Clinical Associate
Course Director CYP IAPT Management and Leadership
Course Lead CWP Supervisors and Service Development Leads
Disclaimer: This is an independent blog and ACAMH may not necessarily hold the same views.

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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.

The government’s consultation on children and young people’s mental health is now available:

Discussion

Total agree! Services will become front loaded forced to focus on the front door with little resources and ability for through-put and actually helping CYP and those who care for them to recover. Hidden waits will emerge if we seek just to put under the microscope 2 or 3 sessions on at the start of the journey . How long will it be thereafter until a child, young person or family is offered actual meaningful sustained engagement and a helping relationship to aid and prompt recovery? Will we the have to mointor the 3rd, 4th or 5th appointment to avoid hidden waits; when we should foucus on outcomes and quality i.e. the result of the intervention and clinical input being delivered and how those engage and supported in services rate their support and have a voice. COME ON OUTCOME FOCUS – Experience of service questionnaire (chi Esq), Outcome Rating Scale (ORS), Session Rating Scale (SRS) and yes Duncan Goal based outcomes (GBO)!

Yes – that’s how I see it!
I really hope I’m wrong!
It’s not too late to collect quality output measures as you suggest – the more quality data we have the more we can balance the drive back to quantity thoughput measures. We need both to monitor good services
Thanks for your comment
Duncan

Hi Duncan, we have real experience of this, there is a 28 day target of referral to assessment in Wales, and then 28 day target to treatment. This is enshrined in law and services have to report back to government monthly on whether mental health services have hit the target 80% of the time. It evidences what you are highlighting as the problems. For example services have internal waiting lists (of months) for children who have been seen a couple of times but need more therapy because they don’t have the capacity to be able to meet the 28 day target and deliver interventions. Services can become focused on signposting children rather than delivering services. Small teams struggle if there is sickness or leave, the pressure on the rest of the team to meet the target is very high. Small teams also struggle with fluctuations in referrals. This is also very stressful for staff in mental health services. Although early intervention/prevention is included in the legislation it is not measured currently, so the waiting time target dominates and takes over when the pressure is on to meet the target everything else stops. Currently there is no requirement to measure quality. This has been in legislation since 2010, there has been some recent review of the legislation but the waiting times remain the main target.

Not so long ago when waiting list targets were being foisted on CAMH services for the first time, I argued with an NHS manager who said that s/he was not concerned with outcomes, s/he only wanted to reduce waiting lists – the CAPA system was introduced as a result, but quickly silted up.

I agree with Duncan, outcomes based on client perceptions are what counts, not clinician rated outcomes which are too easily swayed by adult perceptions and the pressures that the adults are under to deliver to the wrong easily measured targets. There is plenty of evidence that child, parent and clinician ratings differ markedly.

Thanks for your comment Tim
I left a trust once when the chief executive said they were only interested in seeing people quickly and not interested in clinical outcomes. I think it was a defensive position and driven by self-interest – our children and young people deserve better.
I hope this isn’t the case with the green paper?
Time will tell…..
Thanks again
Duncan

Well said Duncan – keeping the balance right between quantity, quickness and quality is going to be the challenge. However these things are only in tension when resources are too tight and pushing for the money must be the biggest priority right now. We need targets for all ‘3 Qs’ above if commissioners are actually to put any resources to them. In developing a new CYP workforce to address these needs we also need to think about where services dedicate experience and higher skill levels – I would want the most experienced staff doing the assessments by 4 weeks, making formulation driven treatment plans which can be delivered by others – but maybe that is just a dream too far?
Helen Pote

Hi Helen
Completely agree! I hope those putting the finishing touches to the green paper take heed!
Thanks for commenting
Duncan

I agree that such an ambitious target, without investment in staff and training to match, is not helpful. Kathryn Pugh at the recent college of psychiatrists meeting said that CCG investment in posts were a target [or were going to be?]. I definitely think staffing levels should be measured though of course that’s only part of the story. Kathryn did put an emphasis on outcome measurement so maybe that’s in the unleaked and less sensational part of the document….I’d glad you mentioned prevention and I hope that there is recognition in government of the need for investment in schools and social services as well. Child and adolescent mental health has been a major and recurrent focus of media attention, it’s just a pity that we still have such a long way to go.

School nurses ideally placed to promote, prevent, id and offer early help. Sadly many being decommissioned as they failed to demonstrate the ‘so what’, the impact of their interventions on cyp health and well-being. Many could, however, offer reams of ‘contacts’. I would share your concerns Duncan et al. This investment needs to be across the children’s workforce and empower self help/management, including CAMHS rather than it being seen as the panacea. Then outcome measures used at each and every contact to enable us to assess if we really are making a difference and if not, permission to stop, reassess, review and agree a new way forward. We have and risk wasting even more precious funding-we can not afford to fail-again!

Hi Duncan, I completely agree with your concerns and see a dangerous trend in ‘assess and pass on’ because the concerns are ‘not severe’ enough of ‘social rather than mental disorder’. I would go a step further and observe that the whole clinic based model is failing to meet the needs of our most vulnerable children – especially here in Wales where we have significant pockets of severe deprivation. I have proposed an alternative model to the traditional four tiered approach to try and address this worrying trend of separating mental from social in response to ever growing demand:
https://weneedtotalkaboutchildrensmentalhealth.wordpress.com/2017/11/10/my-video-of-a-power-point-on-reforming-child-and-adolescent-mental-health-services-7-seconds-per-slide-but-hang-on-in-there-it-is-worth-it/

We waited 7 months for early intervention from CAMHS. By that point what was a very worrying situation had turned into a potentially life threatening crisis. We were desperate. 18 months on our daughter is out of school, recovering still but I fear we passed a ‘tipping point’ for her mental health (aged 8) compounded by teachers and school leadership with Dickensian ideas about education & children, fully supported by the ‘Education Welfare System’ (or what should be named the ‘Compliance System’). We are exhausted by it. I am deeply ashamed of what we as a country are subjecting our children and young people to. On a personal level we are picking up the pieces. Only far reaching systemic change will work. This is another token gesture by disingenuous politicians.

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