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Does no one ever listen to me?

February 5, 2015

By Basket Press

Face/palm! Head/desk! Head/wall!

I’ve just read the front page of The Observer of 1st February, the item about a shortage of Children and Adolescent Mental Health Service (CAMHS) beds and admitting young people to adult Mental Health (MH) beds…Oh noes! How did this happen? Surely someone noticed?
Well, yes, I believe we did. Not that anyone listened.

Young people under the age of eighteen being admitted to adult MH beds has long been, to use the relevant management speak, a “never event”, i.e. it is never to happen: the 1983 Mental Health Act says it shouldn’t happen, MH trusts have issued strongly worded “guidance” to clinicians saying it must never happen…Except, apparently, for when it is politically expedient to do so.

The attentive among you will recall I mentioned this very issue of CAMHS bed shortages and cuts to community services in my first post here, so I am going to go over some old ground.
In 1988, as a newly qualified staff nurse working on a newly opened sub-regional CAMHS in-patient unit, I was part of a staff group who brought to the attention of management that we were not commissioned to provide urgent or emergency admissions, highlighting the potentially severe problems inherent in this. Nothing happened and we had to take the flak from GPs and the like for not accepting urgent admissions – not commissioners nor even our management, but the frontline clinicians, especially Buggins here in charge of the Friday late shift, as I often was.

This unit also lacked anything resembling a psychiatric intensive care unit (PICU), which we also pointed out. The upshot of this was that we had to somehow contain some very disturbed and out-acting young people on an open ward, while still providing a service to the rest of our patients.

These glaringly obvious omissions, which caused many, many difficulties, were not rectified until about five years ago when the local in-patient unit was eventually reconfigured to provide such services (I’m afraid that at the official opening I did very snarkily thank a far-too-full-of-themselves manager for finally listening to clinicians after over twenty years of asking).

In the mid-’90s I was a ward manager on another new CAMHS ward, which likewise wasn’t commissioned to provide urgent admissions facilities or anything like PICU. We did draw the attention of higher manager and commissioners to this, to no avail. (As an aside, the commissioners awarded the contract for this new service to the cheapest bid; there was another, more expensive, bid which would have provided a better service. How do I know? My brother-in-law wrote it, after having picked my brains. What I didn’t know then was he had been told by his chief exec to write a bid expensive enough to look good but still put off the commissioners…And, innocently, I gave him the details with which to do this.)

A few years later, in my first community job, again our local CAMHS ward was not commissioned to provide urgent admissions, which meant a rota of on-call nurses, including the community teams, to provide staff to cover emergency admissions of young people to paediatric or adult MH wards.

Spool forwards into the early years of this century, when I was working in overdose assessment, and I can provide several examples of colleagues and I playing “hunt the bed”, on the phone ringing CAMHS wards the length of the country as our local unit was full…

Then forward further to my last community job: for some time our staffing was almost OK, albeit still below National Service Framework recommended levels, and we could manage young people at home who would otherwise have been admitted. However, this didn’t last long and even before the 2010 election, staff numbers were cut – usually by the sneaky means of keeping posts vacant after someone left or not providing maternity leave cover. This worsened after 2010 and posts were cut. Allied to this other services for young people – school nursing, educational psychology and welfare, charitable sector schemes – were also cut, meaning that more young people were referred to CAMHS, often with more severe problems than had been the case previously. And we were being overrun, and started making more referrals to inpatient services…

Now, this is not hard to work out and it is not, as I have shown, something new and unknown. As I mentioned in a previous post, the likes of Young Minds (who seem to be listened to more than mere clinicians) have published reports detailing cuts in CAMHS and related services, and even the Royal College of Nursing has noticed that MH nursing posts have been hacked to ribbons.

What we have here is the falsest of false economy: many long-standing MH problems begin in adolescence, or earlier, and there is a better chance of a successful outcome if one can stop patterns of behaviour or thought becoming too entrenched; intervening as early as possible will save money in the longer term and will give more people a better chance of a better life. Cutting such services may provide a short term cost saving but is storing up problems and preventing people living a decent life. If one wants to reduce it to money, then we can look, à la Layard, at the economic benefits to society as a whole of getting people back into work and paying taxes.

Personally, I prefer not to do that and go instead back to my Methodist upbringing (I’ve rejected the “god” bit but retain a lot of other principles) and feel that it is a duty to help others as best we can.

Whichever way you approach this issue, the inadequacies of service provision and the consequences have been known about for a long time. Clinicians and families and others have endeavoured to get those in power to listen, so – politicians and commissioners, why didn’t you listen? Why have you allowed this situation to continue? Answer for your wilful ignoring of what we have been trying to tell you! Take responsibility for your inactions!

  1. lesley58 permalink

    From a similar fellow Methodist ! Another excellent post. Don’t you think mental health suffers because the sufferers don’t really have a voice?. I am speaking of both adult and child mental health.

    There doesn’t seem a desire to listen to parents, carers or other relatives and particularly in adult MH issues confidentiality is used to prevent discussion about care. Is there any wonder Mental health has been the poor relation and will continue to be so when services are commissioned often by those who do care more about costs than care.

    CEO’s can tweet all they like about how great their services are but the question needs asking, as long as they are doing the bidding of the finance department do they really care either?

  2. Basket Press permalink

    Thanks Lesley!

    I am really not sure how much higher management actually listen to user voices: my old service did conduct extensive exercises with our young people to ascertain their views (a couple of colleagues won best practice awards for this); the senior manager responsible for us regularly trumpeted their desire to have greater user involvement (I had several arguments with them over this issue) but then oversaw “re-structuring” which did precisely the opposite of what our young people had said, i.e. removing continuity of care, reducing staff numbers so that quality and quantity of service was reduced, preventing staff specialising in particular areas and developing real expertise, reducing the range of treatment options available. I know that similar things happened in other areas of the trust.

    I concluded that “user involvement” was, as far as much management is concerned, one of those boxes they have to tick to get brownie points/bonuses rather than a real thing they have to do and take notice of.

    Also, my colleagues and I, not just in nursing, took very seriously the idea of acting as advocate for our patients. However, in trying to act on this we came up continuously against the mindset that anything clinicians say about service delivery is driven by their own vested interests and can thus be dismissed. Hence my jokingly petulant title for this piece…

  3. lesley58 permalink

    I don’t think your title was petulant at all but sadly the truth.

    Head bang wall, head bang wall. CBE, CBE Two sides of the story !!!

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