Judge’s candour over ‘disgraceful lack of provision’ for vulnerable 17-year-old again highlights CAMHS’ inadequacy – but nothing changes
Sir James Munby’s 19-page judgment on X’s situation contains many views expressed with notably more candour than appeal court judges usually deploy.
But one in particular will resonate with children with mental health problems and their families who have endured frustration, agony and even fear from experiencing the postcode lottery of trying to find what in NHS-speak is a tier 4 CAMHS bed – a place in a children and adolescent mental health services inpatient unit for an under-18 whose condition means they require round-the-clock care.
“What this case demonstrates, as if further demonstration is still required of what is a well-known scandal, is the disgraceful and utterly shaming lack of proper provision in this country of the clinical, residential and other support services so desperately needed by the increasing numbers of children and young people afflicted with the same kind of difficulties as X is burdened with. The lack of proper provision is an outrage,” he said.
The facts are as follows. There are 1,459 CAMHS beds in England, of which 124 are classed as “low secure”, the type that 17-year-old X needs to be in. Just over half are provided by the NHS, the rest by various private health firms. CAMHS beds have increased by 71% since 1999, according to research published last week by the Education Policy Institute (EPI).
Yet, with more under-18s suffering serious psychological distress, including some with psychiatric disorders, no one thinks that the 1,459 are enough. Some areas – the south-west and Yorkshire and the Humber – have particularly low numbers of beds. Suicide has replaced accidents as the biggest killer of teenagers and those aged under 25.
NHS England has promised to create 150 to 180 more tier 4 beds, which mental health bodies have welcomed. But that does not help X, or the many health professionals and social workers trying to find her a place in a unit that will be safe and, crucially, therapeutic.
However, as Munby has found: “There are, across the country, six low secure units at which X could in theory be placed – if any of them had an available bed. Absent an unexpected early discharge, however, none has an available bed for several months.” The unit deemed best for her has a six-month waiting list.
Beds do not become free often, partly because there are too few, but also because those in CAMHS low secure units tend to have conditions – such as personality disorders and suicidal thoughts – that require long-term care. For example, psychiatrists say that X needs at least 12 to 18 months of intensive residential treatment before she can even be considered for discharge.
She has had to be restrained 117 times in the last six months and has committed 102 “significant” acts of self-harm and 45 assaults on staff in that time. Her chances of recovery, and indeed of staying alive, clearly require her to be in the right place once she leaves detention on 14 August. But at the moment X’s situation looks bleak; “desperate”, says Munby. Weeks of intensive effort by Cumbria county council officials and senior NHS mental health specialists have failed to turn up a suitable bed.
Could X end up being treated on an adult ward, perhaps as a stop-gap until a low secure CAMHS bed becomes free? That should be unthinkable; seeing adults with serious mental illness can further worsen a child’s condition. But 83 under-18s were treated on adult wards for 2,700 days in all in the last quarter of 2016. The other possible alternatives, notably treatment on a paediatric or adult ward in an acute (general) hospital, would be even less appropriate – and more risky.
Inquiries by learned bodies have been highlighting the CAMHS beds shortage since 1997. Just last week the EPI revealed that the entire south of England ran out of CAMHS beds twice in April 2016, and London once in June 2016.
The failure to make more beds available is partly due to the low priority historically given to CAMHS, though that has changed in recent years. Many specialists in the field agree with the sentiment expressed by one, that “if mental health services are the NHS’s Cinderella, then CAMHS are Cinderella’s Cinderella”.
X’s plight has gained attention because a prominent judge has spoken about it in dramatic terms. But she is certainly not the first young person in an extremely vulnerable mental state to be denied potentially life-saving care because what is available is woefully inadequate to meet rising need. Sadly, she will not be the last.
Unmet need caused by patients experiencing an overloaded A&E unit, or a GP surgery where getting an appointment takes weeks, often involve relatively minor illnesses. But failure to diagnose and treat quickly someone who is mentally ill can have disastrous consequences. As Norman Lamb, who was care minister in the coalition government, points out in relation to X’s case: “This is tragically not as unusual a case as people might think. Many lives are lost due to such failures in the system.”
By: Denis Campbell Health policy editor