The shambolic, shocking and shameful services provided to children and adolescents with mental health problems in north Kerry were outlined in a report from Dr Colette Halpin on Wednesday. Many reading it will, like myself, have repeatedly paused, dazed in disbelief at its findings.
The independent review of files of 374 patients on the north Kerry Child and Adolescent Mental Health Services (Camhs) database in November 2022 has led to calls for more extensive look backs there and across more services. Legal actions will surely follow.
So what are the findings? What can and is being done to improve things? And why does the current governance model of Camhs restrain progress?
The report identifies “risk of potential for harm” in more than half the cases reviewed. Very high rates of prescribing of psychotropic medication were also associated with failures to undertake recommended monitoring and assessment of physical health and “a disproportionately low rate of individual or family/systemic psychotherapeutic interventions”. While prescribing rates In Ireland are high by international standards, the rates for the Camhs group reviewed in north Kerry at 79 per cent was twice the HSE reported national average; with only half as many offered any form of psychotherapeutic interventions. According to best practice, drugs are adjunctive treatments and should not be prescribed without accompanying psychotherapeutic services, particularly for children and adolescents.
According to the report, children with complex presentations with an intellectual disability and co-occurring mental health problems were mostly assessed only by a psychiatrist, with just one in seven having assessment by another discipline. That 94 per cent of children with an intellectual disability (on a specialist Camhs team) were medicated is deeply disturbing, as is the prevalence of polypharmacy (the generally poor practice of prescribing multiple drugs). There is nothing about having an intellectual disability that means a child will necessarily have mental health difficulties, and so this degree of overmedication is difficult to grasp, discriminatory, and counter to the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). The report suggests 89 per cent of these children were at a greater risk due to their medications, while assessment and monitoring were virtually absent.
Across those reviewed there was no evidence of informed consent to medication in the majority of cases, and no or poor use of established protocols, which is particularly concerning. It’s important to say that at this stage we cannot generalise these findings to other areas, and we do not know the extent to which some of these poor practices and disregard for protocols reflect the lack of more appropriate services to make referrals to. However, this does not explain the failure to obtain informed consent from children and their parents before administering psychotropic medications.
At least some of the issues identified in the report are being addressed. For instance, poor working relationships between Camhs, primary care and disability noted by the review team are being addressed both by the newly introduced integrated health areas and specifically by creating a single point of access, where teams collaboratively decide how best to support someone and collaborate where needed. Workshops across the six new regional healthareas are currently under way to implement this.
The lack of provision of psychotherapeutic interventions is being incrementally addressed by providing more training places for the disciplines that provide such interventions on existing university education programmes. We also need additional training programmes, ideally situated in those areas where it has traditionally been difficult to recruit or retain such staff.
There has been a striking reduction in the use of restrictive practices such as seclusion and physical restraints. This has been achieved through promoting the use of skilled de-escalation procedures, greater person-centredness, and rights-based strategies. How did this happen? The Mental Health Commission imposed new rules in a decisive top-down fashion. Camhs is reported to have seen more than a 90 per cent reduction in the use of restrictive practices in recent years. The impetus for these changes did not come from either service providers or their associated clinical governance, but from those outside with the commission assertively reaching in to address poor practices.
Consider our national governance structure for mental health. The HSE explicitly states on its website that the mental health programme is a “collaboration between the HSE and the College of Psychiatry”. No mention of the professional bodies of psychology, occupational therapy, nursing, social work, speech and language therapy.
In mental health services, where multidisciplinary care is widely known to be best practice and produce the best outcomes, why does governance of the national programme still include just one of the relevant disciplines? And why has the HSE decided to restrict the two National Clinical Advisor and Group Leads positions and the four clinical leads for specific mental health programmes to just one discipline – psychiatrists. The regional leads roles are restricted to psychiatrists, and the lead for each community team in child and in adult services is restricted to psychiatrists.
The current HSE chief executive was a social care worker and our incoming chief an occupational therapist. Both are considered capable of leading one of the largest healthcare organisations in Europe, but apparently not a small Camhs team. Whilst mental health services have moved increasingly into the community, they have brought the structure of the old asylums with them. A straitjacket is of course meant to constrain movement and that is exactly what the governance of mental health services is doing and seems intent on continuing. It is somehow ironic that the services have succeeded in substantially reducing the use of physical restraint, yet the entire mental health system continues under this restraining governance model.
Ten others were involved with Halpin in the review of services in north Kerry. The report doesn’t list their names but they were all psychiatrists. Public servicers require transparency. Members of a group assessing a supposedly multidisciplinary service, should, of course, also have been multidisciplinary. Ironically, their own lack of disciplinary breadth is one of the features they were very critical about in the services being provided. Any further reviews should be multidisciplinary.
Disability services in Ireland are competency led – this simply means the person assessed to be the most appropriate in a competency-based interview is appointed and can be from any discipline.
There is a lack of good governance in Camhs – that is governance reflecting the voice of service users and the full range of health professionals expertise. The truth is the discipline of psychiatry has Irish mental health services in a straitjacket. Governance structures at every level of mental health services are dominated by psychiatrists. Unless we change this narrowly focused governance model, we will continue to have unsafe treatments and the voice of the majority of Camhs staff will continue to be ignored. Ironically, Halpin’s report itself also reflects this myopic unwillingness to address the fundamental weakness in governance in our mental health services.
The straitjacket needs to come off. I have the privilege of working with some fantastic psychiatrists in Ireland, but I also have encountered some psychiatrists who are clearly not competent to lead a team; others wish to protect their profession or their personal power, while others still might like things to change but fear disapproval from their colleagues, or feel such change is too uncomfortable or too complicated.
What will the Government do now? Will they expect improvements by strengthening the old medically dominated mental health system – will they opt to tighten the straitjacket? Or will they see the Kerry Camhs experience as a watershed for mental health? The moment when a vision for change can be shared equally across service users and all disciplines. There is no law or requirement from the Department of Health for community teams to be led by a psychiatrist, they could just as easily be led on a competency basis just as they are in disability services. It’s time for the Government to learn from the success of the Mental Health Commission. I congratulate Halpin (and her team of psychiatrists) on an important and useful report. But there is no point in a look back that results in continuing to do the same things again and again, that will not produce a different outcome. It will not produce the change we need.
Mac MacLachlan is a clinical psychologist and professor of psychology and social inclusion at Maynooth University