Child mental health services ‘may worsen’ up to 2030 due to staff shortages, experts say

Serious shortcomings in Child and Adolescent Mental Health Service (Camhs) will continue and even worsen in the period up to 2030 as shortages of psychiatrists become more acute, those working in the system have warned.

Child psychiatrist Fiona McNicholas, who works in Camhs and in Crumlin children’s hospital, said “root and branch reform” of Camhs was needed to make it an attractive workplace for child psychiatry graduates.

“We know of the [650] psychiatrists currently available, over the next decade more than half of them are going to retire or leave.”

Figures from the college indicate just 167 psychiatrists will graduate between now and 2030, but 400-500 additional psychiatrists will be needed to replace those leaving and meet increased demand.

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In an interim report on Camhs published on Monday, the Mental Health Commission (MHC) identified serious risks to the “safety and wellbeing of children” using the service including poor medication monitoring, understaffing, overworked and unsupervised staff, lack of care-planning, inconsistent care, poor risk-management, and chaotic, paper-based record-keeping.

It found lack of staff with high staff turnover, lack of capacity to provide needs-based therapeutic programmes, lack of clinical governance and long waiting lists.

Highlighted was “difficulty in recruiting and retaining Camhs consultant psychiatrists”, resulting in some Camhs teams “resorting to telepsychiatry”. In south Kerry Camhs, a consultant psychiatrist is providing 23½ hours of cover online from the Middle East.

In the midwest 140 children had been “lost” – ie, left without follow-up care – while children in other areas were left on antipsychotic medication for up to two years without review.

The MHC found “in some teams [there was] a reliance on psychiatrists not registered as specialist Camhs consultants”.

Frontline workers across the health service echoed the commission’s findings. The Irish College of General Practitioners expressed members’ “deep frustration at the high level of Camhs referrals declined, and the lengthy waiting lists for essential mental health services for children”.

The Irish Hospital Consultants Association (IHCA) said 23 consultant posts in psychiatry were “not filled by doctors on the specialist register”.

The IHCA said this was “a serious indictment of Government policy and a sad reflection of the current working environment with consultants no longer wanting to work in unsustainable conditions”.

The report “didn’t tell us anything we didn’t already know”, said Prof McNicholas. “But maybe for the first time [the HSE] is beginning to listen.

“There needs to be a whole-systems change where the HSE looks at the planning, the management, the governance of Camhs... A mental health lead working at senior level is needed. If they made the service better, with a proper IT infrastructure as a minimum, then Camhs would be more attractive.”

Unless the significant gap between projected requirement for psychiatrists and numbers graduating was bridged, she said the situation in Camhs “will get worse, yes”. She added: “It’s appalling.”

Roisin Clarke, interim chief executive of Mental Health Reform – a coalition of more than 80 organisations working in mental health support and advocacy – echoed a call in the report for “different models of Camhs provision” given the difficulties recruiting psychiatrists.

The report says: “It is unlikely that recruitment of staff will improve in the medium term as this is both a national and international problem. The current situation is not sustainable. Repeatedly stating that ‘there is a recruitment problem, and we can’t get staff’ is not going to solve the difficulty and other models of delivering a mental health service for children must now be considered.”

It describes as “outdated” the Camhs approach which “depends heavily on a model of care in which the consultant psychiatrist has responsibility for all children accepted for treatment” adding it “disempowers other professions in the multidisciplinary team and may reduce the attractiveness of consultant Camhs posts to potential international recruits. It is also unsustainable with the current medical workforce.”

A spokeswoman for the HSE said it was “expected” the posts of mental health service director and a mental health lead for children would be advertised in the coming fortnight.