The Irish Times: Lack of specialist child mental health resources far from surprise
In the wake of the Maskey Report into HSE South Kerry CAMHS, Dr Ian Kelleher, a Consultant Specialist in Child and Adolescent Psychiatry, and associate professor at UCD’s school of medicine, outlines the historical and ongoing issues in the resourcing of child and adolescent psychiatry services in Ireland.
This article was first featured on The Irish Times website and can be viewed here.
The Maskey report on the Health Service Executive’s south Kerry Child and Adolescent Mental Health Service (CAMHS) has brought sharp focus to the state of the nation’s specialist child mental health services. The report has, quite rightly, taken up countless headlines over the past week. It was “shocking” said the Taoiseach, “beyond comprehension” said the HSE chief executive.
As a consultant child and adolescent psychiatrist reading the report, and as a parent, I was deflated, upset and angry. Those children deserved a far higher standard of care. But was I surprised by the findings? Shocked? Not in the least.
And anyone who claims to have been surprised either knows very little about Ireland’s crumbling mental health services or was simply playing to the gallery.
CAMHS is the specialist HSE service for children and adolescents with moderate to severe mental health problems, covering a distinct geographical catchment area and led by a consultant child and adolescent psychiatrist. Each CAMHS team cares for hundreds of children and adolescents with, for example, anorexia nervosa, depression, obsessive-compulsive disorder, attention-deficit hyperactivity disorder and psychosis, as well as young people with suicidal thoughts and self-harm. It is, quite clearly, a high-stress clinical environment.
You might expect, given that our role is to treat some of the most vulnerable children in the country, CAMHS teams would be adequately resourced. This is, in fact, a myth that has been repeated ad nauseam over the past week by the Government, including by the Taoiseach in the Dáil, almost as if repeating the myth over and over again makes it a reality.
Budget and resources
Here are the disturbing facts about CAMHS resourcing:
- The World Health Organisation advises that 12 per cent of the country’s overall annual health budget should go to mental health, as happens, for example, in the UK. In Ireland, however, only approximately 6 per cent of the health budget goes to mental health annually. Last year, in fact, when the mental health fallout from the Covid-19 pandemic on children and adolescents had become frighteningly clear, with an exponential increase in referrals to Camhs teams, just 5.1 per cent of Ireland’s healthcare budget went to mental health. You read that correctly: the mental health proportion of the overall health budget actually fell last year.
- There should be 100 specialist CAMHS teams in Ireland. There are only 73. Looking within the individual teams, many are grossly understaffed, some working with just one-quarter of the recommended level of staffing. Clinicians are stretched to the limit trying to keep up with urgent referrals and provide quality care.
- It should go without saying that each CAMHS team requires a specialist child and adolescent psychiatrist. But, as we learned from the south Kerry report, there are CAMHS teams where this is not the case. Imagine a specialist cardiology service being run without a cardiologist. Or a specialist cancer service being run without an oncologist. This is the reality of what was happening in south Kerry and what is still happening in a number of specialist Camhs services around the country. That this resulted in major failings should come as a surprise to no one.
- Each of Ireland’s nine mental health catchment areas (called “Community Healthcare Organisations”), in addition to their routine Camhs teams, should provide a specialist CAMHS eating disorder service. Only two of the nine areas are currently funded to provide such a service. Each of the nine areas should also be funded to provide a specialist CAMHS psychosis service. None are.
- There should be at least 16 CAMHS day hospitals – a step-up service from outpatient CAMHS that allows an increased level of specialist care for children who are more acutely unwell and which can also prevent the need for inpatient admission (which is available in just three counties in Ireland). The last HSE report showed just two day hospitals in operation. In reality, most teams have no access to a day hospital.
- Simple medical investigations like blood tests and ECGs are not routinely available in CAMHS. Instead, doctors need to ask GPs or paediatric hospitals to plug this gap and carry out these basic tests for us. When it comes to more advanced investigations that should be routinely available to consultant child psychiatrists, like neuroimaging, forget it.
Does this sound like CAMHS is adequately resourced?
Of course, even if the Government were to suddenly provide funding for all of these shortages, which, in the wake of the Maskey report, it absolutely must, there is a national crisis in the recruitment of medical consultants. There is no pool of child and adolescent psychiatrists waiting to take up consultant posts here. A major contributor to this is the two-tier salary system for consultants, resulting in senior doctors being paid completely different salaries depending on whether they completed specialist training before or after 2013. It is no surprise then that so many consultants choose to move abroad rather than face the daily insult of being paid 30 per cent less than their colleagues for doing exactly the same work.
Any government serious about addressing the CAMHS crisis and consultant recruitment crisis would address consultant pay disparity immediately. It would also increase funding for postgraduate medical training in psychiatry so that more doctors can complete specialty training and, therein, increase the pool of available specialists. The HSE itself estimates it will need a further 245 consultant psychiatrists by 2028. Where are these consultants going to come from?
The Taoiseach’s response to the south Kerry CAMHS report has been to direct that there be an audit of CAMHS nationally. We do not need an audit to know that the teams are not delivering best-practice care.
Clinical excellence is not reconcilable with gross underfunding and under-resourcing. That is just basic logic.
What should be audited is correspondence to and between members of the Government about under-resourcing of CAMHS to see just how “shocked” they can really claim to be.
The south Kerry CAMHS report revealed a scandal – but not just a scandal of one unsupervised junior doctor; it is a scandal of repeated political failure. These scandals will reoccur and reoccur – and children will come to harm – until the Government gets serious about investing in specialist mental healthcare. The young people of our country deserve better.