Dr. Philip Dodd:

As outlined in the 2017 HSE mental health division operational plan, the division remains focused on developing CAMHS throughout the country. The division acknowledges that a broad range of services support the mental health and well-being of children and adolescents. The term "CAMHS" - or "child and adolescent mental health services" - is applied specifically to services that provide specialist mental health treatment and care to young people up to 18 years of age through an approach involving multidisciplinary teams treating moderate to severe mental health disorders.

CAMHS is only one part of a larger health system that addresses the mental health and well-being of young people. The system includes services at primary, secondary and tertiary care levels. As a specialist service, CAMHS sits within the secondary and tertiary care levels. The mental health division is committed to working with its partners and stakeholders, in primary care and social care in particular, to develop a comprehensive range of services to support the mental health of children and adolescents. Actions in this regard include the continued investment in and development of Jigsaw Youth Mental Health Services across the country; the HSE mental health division has allocated resources at primary care level to recruit 120 assistant psychologists to develop early intervention services for young people, with the likely impact of reducing inappropriate CAMHS referrals; working collaboratively with the SpunOut youth website to improve information on understanding and accessing CAMHS; joint working protocols between key HSE services are being developed to assist teams in collaboratively supporting young people with complex needs who require an input from a variety of specialist teams across mental health, primary care and social care services, as well as services for people with disabilities; and contributing positively to the national task force on youth mental health in readiness to implement the HSE's mental health division's specific final recommendations

It is generally accepted that, although A Vision for Change made clear recommendations for the provision of resources for CAMHS, they have not yet been fully realised and current capacity falls short of what is required. Despite a net increase in CAMHS staffing, from 622 in 2010 to 842 in 2015, most community CAMHS teams across the country are operating at 50% of the level recommended in A Vision for Change, this despite significant investment in CAMHS in recent years and intensive staff recruitment efforts. Mirroring the position across the health service in general, staff recruitment is a significant challenge, in particular nursing and medical recruitment. Attracting consultant psychiatrists to work in CAMHS is especially challenging, with many citing pay and conditions as a reason for seeking employment in other speciality areas or jurisdictions. The underdevelopment of CAMHS teams and staff recruitment problems together significantly contribute to the development of long waiting lists for assessment, inadequate out-of-hours CAMHS services and inappropriate use of acute admission services. This is in the context of significantly increased referral rates. Between 2010 and 2016, referral rates to CAMHS increased by 63%, while the referrals accepted by CAMHS also increased by 66%.

On the availability of CAMHS out-of-hours services varies across the country, currently they are available in about 73% of the country. This is a service improvement priority for the division. There is inadequate provision of CAMHS acute admission services. A Vision for Change recommends a total of 106 in-patient CAMHS beds, with ten secure beds and eight beds to support the treatment of patients with eating disorders. There are four CAMHS acute admission services in Ireland, with a maximum capacity of 76 beds available. If beds provided by private health care providers are included, there is a national provision of 102 beds. However, within the public system there are currently 48 beds operational. The remaining 28 are closed due to staff shortages. There is a specific staff recruitment campaign under way to address this particular staffing issue, with improved service availability expected by September 2017.

On service development, plans are in place to provide an additional 30 beds, including secure beds and beds to provide specialist eating disorder treatment, but they are not due to be online until 2021. Even within the service development plan, there remains a lack of further specialist CAMHS acute admission services such as for the specialist treatment of children with an intellectual disability and a significant mental health problem. As a result, the existing generic CAMHS acute admission services are sometimes tasked with providing highly specialist care in a generic service setting which can result in further service pressure associated with potentially delayed discharges.

A direct consequence of these challenges is children being admitted to adult acute admission units. The decision to admit a young person to an adult unit is not taken lightly and it is always done as an absolute last resort when no other option is available. In making the decision to admit, the safety of the young person is paramount and the decision follows a clinical risk assessment of the young person concerned. There can be a number of factors that influence the decision, including an acute illness and failed attempts to secure a bed in a CAMHS acute admissions centre. A decision to admit a young person to an adult unit must be notified to the Mental Health Commission and be in accordance with its code of practice. In addition, the HSE mental health division is also notified of all such admissions in order to assist in expediting a transfer or discharge from the adult unit as soon as practicable.

On admission, the young person concerned is allocated a qualified mental health nurse on a one-to-one basis whose sole responsibility is to support the young person during his or her admission. Where possible, he or she is supported in a quiet area of the adult ward away from other patients. The priority of the treating team on the adult unit is to support him or her in having access to the appropriate CAMHS team as soon as possible in order that an appropriate care plan can be developed, possibly involving transfer to appropriate CAMHS or children’s services.

On the characteristics of these admissions, the numbers are falling; admissions are becoming shorter and mainly made up of young adolescents. In 2010 there were 163 admissions of young people to adult units, compared to 68 in 2016. Of the admissions in 2016, 88% were of young people aged 16 or 17 years, while 62% of all young people admitted to adult units were discharged within three days of admission. This compares to a figure of 41% in 2015 and 34% in 2014.

While the HSE mental health division is tasked with developing and providing CAMHS in a difficult operating environment, as I have outlined, it remains committed to supporting the development of high quality integrated mental health services for young people in a spirit of partnership with key stakeholders and as part of a whole system approach to supporting young people’s mental health and well-being. Specifically, the division is committed to achieving a further reduction in the number of admissions of young people to adult acute admission units, although it acknowledges that, in exceptional circumstances, the practice may be required to continue in the absence of appropriate CAMHS acute admission capacity and in the context of less than optimal CAMHS provision.