The targets Dr McCulloch is referring to are for every region in England to have a comprehensive child and adolescent mental health service, or CAMHS, in place by the end of 2006. The Government stated its aim of offering a four-tier service, ranging from community-based preventive work to inpatient services for the most seriously ill, in Getting the right start: The National Service Framework for Children, Young People and Maternity Services more than three years ago.
Postcode lottery
But a government report due out this month is expected to show that although progress has been made, there is still some way to go. This is a view shared by Dr McCulloch. "There is no common structure and the postcode lottery is unbelievable," he says. "Where I live in south London you can get treatment for moderate problems quite easily and there are exciting examples of practice in places such as Plymouth, Southampton and Westminster, but in other places it's not much different to the child guidance clinics of the 1960s."
Mental illness is a serious problem among young people. The Government acknowledges that as many as one in 10 young people - that's an average of three pupils in every classroom - experiences some form of diagnosable mental disorder. According to mental health charity YoungMinds, one in 12 young people deliberately self-harms, 80,000 suffer serious depression and two commit suicide every day. An overwhelming 95 per cent of imprisoned young offenders have a disorder.
The Government recognises young people's mental health is a growing area of concern and agrees that services need to improve. Dr Sheila Shribman, the national clinical director for children's health services and one of three co-sponsors of the progress report due out in November, told Young People Now: "We've made an encouraging start but we've still got a very long way to go. There's been more resources, more staff, more treatment, but it's very clear services have been patchy."
Lee Miller, consultancy and training manager at YoungMinds, welcomes the additional investment that amounted to 513m in 2005-06, but says progress has been inconsistent. "There has been good work, but we're nowhere near achieving comprehensive CAMHS - more resources are needed," he says. "The gains made are at risk."
The British Medical Association is sceptical too. In a CAMHS briefing released this summer, one unnamed member is quoted as saying that "the desired aims of a comprehensive CAMHS are a long way from reality... There should be four child psychiatrists in our district and there is half of one (part time)". The association also points to the Government's own mapping exercise for CAMHS, which it claims shows, for example, an increase in the CAMHS workforce of 15 per cent from 2003 to 2004, but within that figure is a local variation between a 40 per cent rise and a five per cent decrease.
That mapping shows that change is happening, counters Shribman. "Yes, there's variability, but the aim is to ensure we get equality of access," she says. "A good deal still needs to be done, but we hope our report will produce a lot of discussion about what the next steps should be. People may think we feel we've dealt with this, but that couldn't be further from the truth."
Government inspectors have also been critical of inconsistency. In a Joint Area Review of Devon, published on 11 October - ironically World Mental Health Day - inspectors criticised the variable implementation of CAMHS: "Inconsistencies between service providers lead to unacceptable variation in how children receive CAMHS."
Overall capacity might be expanding, but it appears not to be keeping up with what McCulloch calls an "epidemic" of mental health problems facing young people: "It's multi-factorial - and includes elements such as the target-driven educational culture, poor diets, sedentary lifestyles and the break-up of traditional family structures that, in some cases, can be bad for young people. Some three-quarters of problems never get treated; it's extraordinary and would never be tolerated in the case of physical problems."
Hard decisions
On the ground this rising demand, coupled with localised financial difficulties, can mean some very difficult decisions. In Birmingham, the primary care trust was recently required to "reconfigure" some of its CAMHS provision, which included closing a ward for younger inpatients because of "budget pressures" of 800,000. In Cambridge, an early intervention service that has been helping young people with mental health problems for some 33 years was forced to close on 29 September after the local primary care trust withdrew 171,000 as part of wider cuts (YPN, 13-19 September, p6). Cambridge Young People's Service is now holding out for help from charities and the private sector.
Many of the 500 young people referred to the service every year have a history of self-harm and suicidal behaviour. They include people such as Tim, 20, who was involved in drug dealing and petty crime and whose problems stemmed from unresolved grief over the death of both parents when he was 12; and Jordan, 21, who was brought up in care and was lonely, frightened and isolated, having been forced to flee his home town after witnessing a violent crime.
Dr Shankarnarayan Srinath, of Cambridge Young People's Service, says that while the primary care trust was establishing some services for young adults, young people would miss out on the holistic approach offered by the service. "You have to see behind the symptoms to the kind of anxieties that drive them," he says. "That is what will get lost. To see young people as conditions is to miss the point."
The Mental Health Foundation's McCulloch believes there are wider problems with CAMHS and wants to see a review of the way they operate. "The model was flawed from the beginning because it uses GPs and schools as the gatekeeper, instead of concentrating on an unbadged generic service in a youth-friendly setting," he says.
"It should not be just about investing in CAMHS, but in a range of services in places young people like in ways they find acceptable. We need to get more radical. It's about getting a product that makes sense to young people and we're nowhere near cracking it yet."
A wider focus
Shribman too wants the next stage in CAMHS to reflect the wider "voice-and-choice" initiative across government: "We've got to improve training for professional staff but also get mental health to be part of the core training of teachers, social workers and youth workers." She also stresses the need to end the use of adult wards for young people with mental health problems, to reach out to Black and minority ethnic groups and to provide further services to groups identified as most likely to suffer from mental health problems.
For YoungMinds' Lee Miller, the way that progress towards comprehensive CAMHS has been assessed - through the use of "proxy measures" including 24-hour cover for urgent needs and a full range of services available for children and young people with learning difficulties - is too narrow. "When push comes to shove they will be seen as the priority areas and could lead services to abandon other areas to hit targets," he says.
For all the shortcomings in establishing comprehensive CAMHS on a consistent basis, Miller does feel that improvements have been made.
"It now feels that children and young people's mental health is recognised as everyone's business, and professional groups are looking at what they can do," he says. "But we've got to maintain that focus. The job is only half done."
GOOD PRACTICE IN SWANSEA
The Storm project is a tier two mental health service in Swansea that works with young people who have consented to a referral and, while they are unlikely to have a diagnosed condition, they do need a bit of help.
Project manager Anne Roszkowski explains: "We work hard at engaging the young people and draw up a working arrangement and support plan with a key worker. It may involve weekly one-to-one sessions or group sessions if they prefer. Staff take a systemic view, encouraging young people to build their own resources of self-confidence and self-esteem. That might involve anything that helps them to make sense of things - cognitive behavioural therapy, art and creative activities. Outdoor pursuits can be a very good way of engaging young people."
The project, which is funded through Cymorth, a Welsh Assembly Government initiative, targets support directly at children and young people. It also works closely with schools, employers or training providers to help stabilise young people's position. Many of the young people have experienced some sort of abuse, about a third will have experienced domestic abuse and a similar proportion will have parents with mental health problems themselves. "Many are withdrawn and isolated and establishing contact can be a real challenge," adds Roszkowski. "Some young people do move on once the chaos has calmed a little, but we need to be around as a medium- to longer-term intervention for them."
Being part of a wider CAMHS means that if workers have serious concerns with any young person they can quickly get them to see a doctor on a one-off basis without having to go through the waiting list, similarly with the family therapy clinic. Referrals also come in from other services within the CAMHS.
Project staff come from a range of professional backgrounds - occupational therapy, mental health nursing, teaching, youth work and psychology. "It seems to have been very, very useful to have that mix; it enriches the service we can offer," says Roszkowski.
"Some young people do move on once the chaos has calmed a little, but we need to be around"
Anne Roszkowski, project manager, Storm
- 10% of young people suffer from mental health problems - 2 young people commit suicide every day - 95% of imprisoned young offenders have a mental disorder.
