Mental health services – underfunding is a political decision

 

Sir, – The Irish Times has taken a compassionate and thoughtful approach to highlighting the South Kerry Child and Adolescent Mental Health Services (CAMHS) scandal (Editorial, January 27th). The pain and suffering borne by children and their families are immense, and the scandal is inexcusable and was totally preventable.

We have heard repeatedly from our politicians that funding is not an issue in this crisis. This is categorically and unequivocally false. The public needs to know this truth. This is particularly false when considering the fact that, in general, some fiscal outlay needs to be made in providing educational resources and supports to junior doctors in training. This fiscal outlay to train an appropriate amount of consultant psychiatrists has not been made and is not being made.

The funding of postgraduate training in Ireland, particularly in psychiatry is, and has always been, in dire straits. The National Doctors Training and Planning unit of the HSE has in a recent publication highlighted the fact that hundreds more consultant posts are needed in psychiatry by 2030 for the HSE to run a safe and effective service for our most vulnerable citizens. Currently one in five consultant psychiatrist posts is vacant.

This year just six new posts in CAMHS higher specialist training are funded. This is horrifyingly insufficient and policy makers must be held to account for presiding over continued inept workforce planning. To get to a place where hundreds of more doctors are trained as specialists in psychiatry will require only two things: funding and political will.

The College of Psychiatrists of Ireland is unique among postgraduate medical training bodies in that it has never accepted any funding from the pharmaceutical industry.

In addition to this, postgraduate training in psychiatry is comparatively underfunded by the exchequer in comparison to other specialities. The College of Anaesthetists of Ireland, a training body of similar size, receives almost twice as much public funding. Postgraduate academic and psychotherapy tutor roles in psychiatry are filled on a completely voluntary basis.

Consultants perform these roles in addition to their full-time jobs out of a sense of duty. Unfortunately, duty in itself does not fund training posts – if it did, we wouldn’t have had this scandal. Funding of training posts and workforce planning need to be at the core of any long-term strategy to prevent a scandal like this from ever occurring again. We have not trained enough psychiatrists. We are still not training enough psychiatrists. This is a problem of political will, and policy.

Psychiatrists do not want to work in “big centres”, contrary to what was stated by our Tánaiste on national radio. We primarily work primarily in small and most often dilapidated buildings in the community. I also note the Tánaiste did not understand what the acronym CAMHS actually stands for. He erroneously said “Child and Adult Mental Health Services”.

Perhaps our policymakers are happy to see the managed decline of State-run services for young people with severe mental illness. This is what we must increasingly interpret from their inaction.

They have been happy to promote funding for new services for mild mental health problems but have left the services for those with the most severe needs in a state of absolute and continuing crisis.

Individual doctors obviously do not train to be consultants in psychiatry for reasons of prestige, as implied by our Tánaiste. It is not a job that typically generates fee-for-service private income, unlike other specialities.

Our patients more often than not live on the margins of society. They are vulnerable.

For policymakers such as our Tánaiste to suggest we seek only prestige is frankly insulting.

This harrowing scandal requires action from politicians, not ignorance, and not quasi-insults. It requires money to train sufficient numbers of consultant psychiatrists and coherent State-led action in reforming mental health services. – Yours, etc,

Dr EMMET POWER,

Health Research Board

Clinical Research,

Fellow in Youth

Mental Health,

Department of Psychiatry,

The Royal College

of Surgeons in Ireland,

Beaumont Hospital,

Dublin 9.

Sir, –In any rush to denigrate particular practitioners as a result of the Maskey report on the child psychiatry services in Kerry Child and Adolescent Mental Health Services (CAMHS), we must ensure that patients and their families receive the best evidence-based treatment available.

Please let us not forget that both mental health and mental illness need treatment. Illness often needs pharmacological treatment in combination with non-medical treatments. Medications must be prescribed and monitored by competent medical consultant psychiatrists on the specialist register of the Medical Council. These doctors must also competently supervise junior doctors who prescribe.

My concern is that the events in Kerry not disadvantage patients with real illness further by denying them effective evidence-based medications prescribed by specialists when badly needed.

No regulation means no change. All managers employed in the HSE must now be regulated by the Government in the same way as clinicians. They must provide evidence of competence and professional development and be subject to appropriate sanctions.

Otherwise, despite the Taoiseach’s statements in the Dáil, the Maskey report, like many before it, will soon be forgotten and nothing will change.

Child psychiatry and CAMHS services do not exist in isolation. They are supposed to be part of a continuum of care from, among others, school counsellors to inpatient child psychiatry CAMHS units.

Any review into the provision of mental illness healthcare to children must address the issue of lengthy waiting lists of all services, including the National Educational Psychological Service, disability, autism, psychology, inpatient CAMHS services, etc, and the imperative of seeing patients based on clinical need.

There are very little to no emergency and urgent mental health or illness services in the country, especially “out of hours”.

The HSE actively directs patients to their “GP or local emergency department”. Frequently the number of inpatients with mental illness in paediatric hospitals outstrips that of inpatient CAMHS psychiatric units.

Yet there is no official mechanism to record any of these paediatric hospital admissions. Hence they do not officially exist. Any review of services must also consider this point.

The best place to provide services for patients and their families – where a culture of patients being seen immediately based on clinical need, 24 hours a day, seven days a week, exists; where there is less stigma; better resourcing and facilities; staff recruitment and retention; peer support across disciplines; appropriate governance; proper supervision of junior doctors; wider continuing professional development availability and culture; easily accessible medical facilities for monitoring medication; and immediate medical psychiatric beds when needed for patients, with facilities for parents to stay – are paediatric and general hospitals nationwide.

Although unrecorded, this immense work is already happening there anyway. Why reinvent the wheel? – Yours, etc,

Dr KIERAN MOORE,

Consultant Paediatric

Psychiatrist,

Teach Thigh na Reanna,

Ros Mhic Thriúin,

Co Loch Garman.

Sir, – I am a parent of a child with additional educational needs, who has comorbid mental health difficulties.

I am also a consultant child psychiatrist.

As a parent, my heart goes out to children and families affected by this recent scandal in South Kerry.

As a parent and child psychiatrist, I am baffled by our Taoiseach’s response that this is not about resources.

Several years ago, A Vision for Change was published, a blueprint for how services should be developed and structured for meeting the needs of adults, adolescents and children with mental health needs.

Many of the recommendations made have yet to be fulfilled.

And here we are, so many years later.

This is not just about a single doctor, a single consultant, a single team. This is about how we value, manage and govern mental health services for the good of our service users. – Yours, etc,

Dr MARIA DUNNE,

Dublin 4.