Collette Isabel Stadler: Rhetoric versus reality in child and adolescent mental health

Achieving “parity of esteem” between physical and mental health is a noble ambition, but it does not reflect the current reality for our youth, says Collette Isabel Stadler

Accompanied by a flurry of media coverage, the escalating child and adolescent mental health crisis has come into the spotlight in recent months, with all the signs suggesting that this is a problem for which the NHS is woefully underequipped. A survey of general practitioners illustrates the scale of the problem, and has brought into focus the challenges faced by NHS Child and Adolescent Mental Health Services (CAMHS).

In the space of only two years, the number of mental health related consultations with young people has increased drastically, with 86% of GPs reporting that they have seen a rise in the number of 11-18 year olds with anxiety. What is of particular concern is that this rise in the number of young people seeking help has not been accompanied by an increase in CAMHS’s capacity to provide adequate mental health support—a point best illustrated by the fact that 99% of GPs surveyed said they were worried about under 18s coming to harm as a direct result of inadequate mental health provision.

Statistics confirm our GPs’ increasing sense of a crisis unfolding. In April 2018, there were 389 727 “active referrals” for under 18s to CAMHS, according to NHS Digital—a third higher than the same month only two years ago. The “burden of disease” threshold for a successful referral to CAMHS is now so high that only the very sickest of young people are seen, and thiscombined with a lack of therapists available in the communityleaves many teenagers with a more “moderate” (but no less distressing) mental health burden falling through a gap in our healthcare system. Rather illustrative of this desperate state of affairs is the official statement released by the government and the NHS in response to the GP survey. This promises a commitment “to ensuring that by 2020/21 35% of all under-18s seeking help get it . . .” It is rather staggering that the government’s goal is to arrive at a situation where two in three young people do not receive adequate mental healthcare.

But how did we get into this mess? In order to solve a crisis, we must first understand its origin. As so often is the case when public services come under strain, the crux of the issue is the combined burden of growing demand and ever scarcer community based, needs led resourcessuch as cognitive behavioural therapyand its funding. Indeed, the number of young people seeking help for mental ill health has increased sharply in recent years, a phenomenon blamed partly on social media by many experts. Concurrently, funding for CAMH and other community based psychological services has been stagnant or even shrinking.

In 2015/16, 40% of mental health trusts in England received a real terms decrease in their operating income. Years of underinvestment will inevitably chip away at a public service’s ability to provide equally and adequately, leaving it a “skeleton” service, which is largely reactive and limited to dealing with patients in extremis. Minimal resources will thus undermine any effort to move towards a proactive system focused on prevention.

In fiscal terms, mental health remains the poor relation of the NHS, a reality that is at odds with the recent political rhetoric of the NHS aiming to deliver “parity of esteem” between physical and mental health. For such equality to be achieved, the latter must be as accessible as the former, as well funded as the former, and held to the same standards of care. Those are noble ambitions whichfor the time being, and at the detriment of our youthremain just that.

How then do we start to bridge that gap, which separates political rhetoric and current reality? Taking into account the root cause of the current crisis engulfing CAMHS, a two pronged approach is needed, tackling both the increased demand among young people (through improved disease prevention) and the lack of resources (through better funding). Funding largely comes down to political will and, ultimately, public opinion. As is true for the NHS in general, higher taxes may be unavoidable. Polls suggest that the public would approve of such a move, particularly if that additional tax is hypothecated (e.g. in the form of increased national insurance contributions).

However, while treatment should remain a focusand indeed be improvedwe must shift some of our focus to prevention and early intervention. Such an approach is likely to require higher upfront investment, but this will almost certainly save money in the long term—not to mention the benefits it would bring to the individual patient. Part and parcel of a preventative approach in healthcare is the aim to improve the health literacy of the entire nation and ensure that mental wellbeing is integrated into every aspect of life. This will expedite the process of destigmatising mental ill health, thus increasing the likelihood of a young person seeking help earlier. It will only be through a concerted effort, and a multifaceted strategy such as this, that we will be able to prevent so many of our young falling through the mental health “gap.”

Collette Isabel Stadler is an academic GP ST1 in Cambridge. Her research interests focus on health inequalities, particularly for vulnerable groups of the population. She has a particular interest in the health of looked after children and care leavers. 

Competing interests: None declared.