Dr. John O'Brien:

My colleague, Dr. Brendan O'Shea, and I are general practitioners. We are here at the behest of the Irish College of General Practitioners, ICGP, whose remit is educational training standards and research in Irish general practice. General practice provides a comprehensive, holistic and an ongoing care of individuals and families over prolonged periods of time, often extending over many generations of a family. It does not simply look at diseases, although it does that also, it addresses the physical, psychological, social and existential problems patients present with. It is a service that is available 24-7, 365 days of the year. GPs know their patients and the context within which they live their lives and, accordingly, they address their problems in that context. It is generally the point of first care and it is also the last resort when other services are insufficient or inaccessible. If the problem cannot be mended, it will eventually end up back in general practice.

Some 75% of the presentations to the child and adolescent mental health services, CAMHS, are referred from general practice, with the remainder coming from a multiplicity of other sources such as social workers, schools, paediatricians and many others. The national audit of waiting times for CAMHS done in 2012-2013 showed that 50% of people were seen within a month and that 70% were seen within three months, but these figures, while sub-optimal in themselves, mask another problem in that they do not demonstrate the variability between one area and another. Furthermore, these figures do not accord with recent reports from GPs of their experience of waiting times, most especially in areas of deprivation.

The distribution of CAMHS is population-based - one team per 50,000 of the population. This crude allocation of resources takes no account of the greater need for mental health services in areas of deprivation. The Deep End Ireland group of GPs has conservatively estimated that the need is twice that of less deprived areas. This is yet another example of the inverse care law where those with greatest need are least likely to have it met.

The composition of the CAMHS is a psychiatrist along with a multidisciplinary team of nurses, psychologists, social workers, occupational therapists and junior doctors. These teams have been missing key staff to varying degrees in different areas. The net effect of this is that these teams are not able to do their work. The case load increases and more staff members leave the team because they are not able to work in a manner which is consistent with their own professional values. In Dublin 15, for example, we had a period where we had no child psychiatrist and this was followed by a further period of repeated changes of psychiatrists. This was not a service in any meaningful sense since lack of continuity is very disruptive. In recent years, CAMHS has defined the limits of what it does and has formalised this in its standard operating procedure. Regrettably, this was done without meaningful reference to its main source of referrals, general practice, and the result has been a cumbersome and fragmented referral structure. A GP must decide at the initial consultation if the child presenting has a leaning disability problem, an autism spectrum disorder, a severe mental health problem or a more minor one. Depending on the evaluation, the child will be referred to the assessment of need service, primary care psychology or CAMHS. Often, this is well within the clinical competence of the GP. However, since the initial presenting story is often complex and poorly defined at the front end, and also since the child's condition often changes while on the waiting list, the referral can very easily be misdirected, thus extending the waiting time even further. A more unified referral structure is badly needed and there needs to be an end to children being referred back to GP with their problems unaddressed, a not uncommon experience for GPs and their patients.

There are 1.15 million people under the age of 18 years in Ireland. It is estimated that 115,000 have a mental health illness, causing some impairment, and 23,000 have severe and disabling mental health problems. Some 5% of the budget is spent on CAMHS. I am not sure if that is 5% of the national budget or the mental health budget, but with that allocation there is still a struggle to provide sufficiently for the need. GPs provide 25 million consultations every year but they are even more poorly resourced at 3% of the national budget.

The cheapest way to deal with childhood mental health is to intervene with resources as early as possible in the evolution of an illness in the domain where it is least expensive. GPs struggle to provide the care needed as they have little and often no resources to assist them. The ready provision of child psychology, family therapy, outreach workers and counselling psychotherapy is often insufficient, patchy or absent. If CAMHS is very expensive, and clearly it is, then the best solution is to properly support GP care where interventions are at their earliest and cheapest. Most importantly, this would save children and their families a great deal of unnecessary pain and distress.

The care of those with an autism spectrum disorder is also fragmented with service schemes for younger and for older children. CAMHS specifically excludes these children from their standard operating procedure, except where acute short-lived mental problems arise. The mental health intellectual disability service for children and adolescents is meant to look after that. This repeated fragmentation of care makes it nigh on impossible for the GP to make sense of what is going on.

The transition from a childhood mental service to adult care is not working. The GPs are being left to care as best they can with the meagre resources at their disposal. The lack of a timely user-friendly mental health service for younger people is undoubtedly a cause of great concern. The unaddressed mental health issues these children suffer now will continue into adulthood and, along with the great distress suffered by them and their families, it is extremely wasteful. The neglect at this early juncture inevitably leads on to greater cost of ensuing grave mental health problems, addictions and criminality. GPs who think in terms of decades and generations can see this unfolding from the perspective of their community-focused clinics. I will now pass over to Dr. Brendan O'Shea.