I welcome the opportunity to discuss the important issue of developing mental health policies and services for young people, particularly child and adolescent mental health services, CAMHS. Promoting positive mental health and well-being is important to us all, particularly as mental health can be a complex and emotive issue. This applies particularly to vulnerable young people who must face evolving pressures and expectations while having limited experience or perspective. Having spent years working directly with young people, I am very aware that they face entirely new challenges that are beyond the experience of older generations. Alongside these are new opportunities to connect and communicate with each other and with services and it is incumbent on us as policymakers to make the most of them. It is encouraging that during my time as Minister of State I have found wide agreement in both Houses of the Oireachtas and among external stakeholders to develop our mental health legislation, policies and services. The Government has consistently prioritised investment in mental health and the HSE has been implementing new or expanded improvements year-on-year. I remain as open as ever to suggestion or constructive criticism that will result in a better CAMHS service. These are often allied to linked improvements around primary care, disability care or early intervention and prevention measures. We must also include enhancements beyond the health system such as those relating to education, justice, childcare or online safety. The best interests and mental well-being of young people must be our first concern in every policy area that deals with them.
The ongoing reform agenda in mental health services has led to much needed change on many fronts, destigmatising mental illness and encouraging open discussion and a recovery focus. Delivering modern mental health services requires adequate resourcing. Beyond that it requires a new outlook to maximise the impact of existing structures and provision. This ranges from addressing acknowledged staff recruitment and retention difficulties to further rebalancing primary care and specialist interventions such as CAMHS. The implementation difficulties we face do not relate to a lack of funding for the key HSE mental health care programme per se. While the fundamentals of our policies and services remain on course, informed by past experience and future needs, there is real scope to do at least some things differently, rather than endlessly expecting more funding to solve problems that can be otherwise addressed. Securing a supply of trained and skilled staff, particularly at consultant level, is a multi-year project and with other countries also experiencing shortages, it is clear an innovative approach is required.
Even in the face of these challenges, developing mental health services remains a priority for the Government and, in line with programme for Government commitments, further investment will continue as overall resources and service pressures allow. Budget 2019 provided an additional €55 million to progress new developments in mental health, which brings overall HSE mental health funding to nearly €1 billion this year. Our aim has been that services become more person-centred, user-friendly, responsive to need and recovery orientated. We have had to respond too, given that demand for CAMHS has increased by over 20% for referrals since 2012. Increasing demands and complexity of cases continue to emerge. A single specialist service such as CAMHS cannot be expected to address all issues.
CAMHS is a specialist clinical service for those under 18 with mental health difficulties that affect their thoughts, feelings and behaviours every day. It is not for everyone nor is it designed to be. Only a small percentage of the population requires access to this service. Some conditions treated in CAMHS include moderate to severe depression, anxiety, eating disorders and self-harm. It has never been a goal to increase referrals to CAMHS. Reducing the number of young people who need this intervention is key, not simply from a resource perspective, but for the sake of the well-being of children and young people. There are now 70 CAMHS teams in place across Ireland. The vast majority of interventions in CAMHS occur in a community setting and this is in keeping with both A Vision for Change and Sláintecare principles and recommendations. Young people with moderate to severe mental health difficulties are referred to specialist mental health services by primary care practitioners such as GPs or psychologists. Specialist mental health services are provided by multidisciplinary teams. These services are concentrated in community teams where only those with needs above that threshold are referred to specialist inpatient settings. Over 90% of mental health needs can be successfully treated within a primary care setting, with a need for fewer than 10% to be referred to specialist community-based mental health services. Of this number, approximately 1% have needs that require inpatient care and nine out of every ten of these admissions are voluntary.
The HSE is committed to ensuring all aspects of CAMHS services are delivered in a consistent and timely fashion, including improved access and reducing waiting lists. In 2015, the HSE introduced a new standard operating procedure for CAMHS. This has helped improve the service overall, including by reducing inappropriate admissions of adolescents to adult units. It has also been a learning experience, prompting services to feed back on how procedures can be improved. On foot of this, a revised standard operating procedure, SOP, is being rolled out. Demographic pressures mean it will always be challenging to maintain the trend of improving access but the HSE is committed to ensuring the admission of children to appropriate units as much as possible and this situation has improved considerably over recent years. The total number of children on CAMHS waiting lists was approximately 2,560 at the end of November 2018. The HSE has prioritised reducing CAMHS waiting lists and particularly the number waiting over 12 months, which was 295 in November. In conjunction with the Department of Health and the HSE, I continually monitor the data nationally to see where further improvements can be made. I have recently spoken to the managers of all the community healthcare organisation, CHOs, and I stressed that I would not be introducing waiting list initiatives because I prioritise real long-lasting reform over short-term solutions. Around 18,000 CAMHS referrals are expected in 2019. Cases assessed by professionals as being urgent are seen as a matter of priority. It is important to point out the figure is an increase from around 12,800 referrals received in 2011. This is a significant additional case load that health professionals are dealing with and is something that is too often overlooked by those who criticise the services. Occasionally, we should all take a step back and look at the very good work being done by the HSE instead of constantly highlighting negative situations because it will not encourage any person to step forward for help at early intervention stage.
There are 76 CAMHS inpatient beds in four acute units nationally with plans for additional beds in the new children’s hospital and the new national forensic mental health complex now being built at Portrane. This is due to open in 2020. I will undertake an on-site visit there on 5 February 2019 and this major capital project is progressing well. The key relevance to the debate today is the fact that a new ten-bed forensic CAMHS unit, the first of its kind in the country, will be provided at Portrane. This should reduce to a great degree the need to send our more complex cases abroad for treatment. As stated, older adolescents can at times be admitted to adult units. This takes place only after efforts to place them in CAMHS units are unsuccessful due to capacity or clinical needs. All admissions of young people under the age of 18 years are notified to the Mental Health Commission in accordance with regulations. All such admissions are also notified to the HSE national mental health service by the regions. It should also be noted that clinicians are not in favour of cut-off points such as a person's 18th birthday. Where inpatient treatment is nearing completion but might need to be continued beyond a person's 18th birthday, consideration may be given by the CAMHS inpatient team to complete the intervention as an inpatient within the CAMHS unit. In such cases, best interest principles must apply. Such principles must take into account the needs of the individual young person who has just turned 18 as well as the other children or young people who are on the unit. HSE national mental health services work closely with local and national CAMHS inpatient services to ensure the clinical needs of the young person are assessed and addressed within the most appropriate setting for the young person and their family.
On 23 January, I convened a meeting with all nine HSE CHOs specifically to review CAMHS. By bringing specialists and managers from across the country together, I am pushing knowledge transfer and co-operative working. The success of day hospital facilities and of nurse-prescribing in respect of attention deficit hyperactivity disorder, ADHD, in some regions was of interest to me.
I will be working with the HSE in order to identify how these initiatives can be expanded.
Another initiative aimed at improving early intervention for young people with emerging and mild mental health difficulties is the enhancement of primary care psychology services through the employment of assistant psychologists. The recruitment of 114 new assistant psychologists is now complete and over 2018 they have become actively involved in primary care teams providing psychological interventions for young people. This major development aims to ensure that young people whose clinical needs are at primary care level receive appropriate intervention, and do not end up on secondary care waiting lists due to lack of appropriate assessment and resources in primary care. Another measure I have brought forward is the training and appointment of ten new advanced nurse practitioners specifically for CAMHS. When these have completed training later this year, they will be directed to areas of greatest service pressures, including reducing waiting lists.
A priority for me is to introduce a new approach to prevention and early intervention in youth mental health care. One obvious and tangible spin-off is not only to provide the level of care appropriate in individual cases, but also to help reduce pressures on the specialist CAMHS service. This initiative has been included in this year’s HSE service plan.
In the context of developing CAMHS, and other initiatives relating to prevention and early intervention, the HSE service plan for 2019 will: continue to implement the recommendations of the youth mental health task force; implement the agreed development of a 24-7 contact line, crisis text line and other e-mental health digital responses; work with sports, community and voluntary groups to develop resilience and reduce demand for mental health services; develop a seven-day-per-week service for CAMHS to ensure supports for vulnerable young persons in line with Connecting for Life; progress day-programme and day-hospital services within CAMHS; develop eating disorder specialist community teams in both adult and CAMHS services; enhance Jigsaw and other early intervention services specific to those aged 18 to 25; enhance access by older adolescents to specialist mental health services and, for those requiring acute admission, their continued appropriate placement and care in child and adolescent-specific settings; and implement the recently developed CAMHS advocacy model. The new funding coming through this year will obviously also be used to enhance existing CAMHS teams, whether acute or community-based.
In the context of pursuing new avenues overall, which will also directly or indirectly benefit CAMHS, we now know from a clear evidence base that many young people wish to avail of information and support on mental health through online channels. While this is not the silver bullet to all problems, the experience of this where is works well in other countries shows significant potential to effectively address many issues here, including benefits for CAMHS.
I have made digital mental health service improvement a key priority. The HSE has embraced this project because the benefits for services are so clear. The digital mental health service encompasses developing online content, signposting of supports and services, and an active listening service based on the provision of text support. This new digital resource will meet significant public mental health need by responding to changing help-seeking behaviours and facilitating the fullest possible range of supports for people experiencing mental health difficulties.
One key initiative is a new website and signposting search tool. The new yourmentalhealth.ie website went live on 10 October last. The public can now find personalised support options through an integrated search tool that generates information on online resources, telephone and face-to-face supports and services relevant to a wide range of mental health issues.