Dr. Aileen Murtagh:

On the outstanding issues related to A Vision for Change, the document was based on a different population base. It has not been fully implemented. As a bare minimum, it needs to be implemented. In particular, it is a matter of looking at investment in community services in the first instance to ensure all of the recommended CAMHS teams are available and fully staffed. My colleagues have highlighted deficits which I have also experienced. These days families are much more informed. When they come to services with a young person with OCD, they know that cognitive behavioural therapy, CBT, is an evidence-based approach and ask for it. They are very well aware of the deficits within the team. It is, therefore, a matter of staffing and putting resources into the community teams in the first instance, certainly in liaison psychiatry. I worked in liaison psychiatry in one of the few such services in the country. On the whole, we were discharging young people from medical beds the next day - it is not the most appropriate placement for a young person with mental health difficulties - once they were medically stable, whereas if there was no psychiatrist available, a young person might have had to wait in a paediatric bed for quite some time in the absence of a mental health assessment to inform the medical practitioners that it was actually safe to send the young person home.

Another area at which to look that is really helpful is the day hospital, as it gives timely access to young people in crisis. There are very few day hospitals in the country. The one that was in Dublin is now shut and unavailable. Because of this sometimes there is nowhere else to send an acutely unwell young person where CAMHS is not sufficient to meet his or her needs and he or she needs a more intensive service. If there is no day hospital available for a young person in his or her locality, he or she will attend inpatient services which puts more pressure on and blocks capacity in them. Conversely, when one is discharging a young person, one wants to minimise the time he or she will spend in an inpatient unit. However, if there is no step-down facility available in a day hospital, he or she might actually remain in an inpatient unit for an extended period because the gap in intensity between CAMHS and the inpatient unit is huge. It is really a matter of looking at investment in community services, as well as the additional 100 beds envisioned in A Vision for Change to meet the needs of the population at the time. We probably need A Vision for Change for children and adolescents alone.