New Frontier for Integration.

Completing our series of 4 blogs for #childrensmentalhealthweek is Ayasha Fisher (@ayasha09017404), CAMHS Crisis Liaison Nurse and Clinical Lead Nurse. She argues that we have some way to go yet before CYP mental health services achieve parity of esteem with physical health services. New initiatives might herald better integration of physical and mental health care which makes it even more important to carefully consider how best that can be done.  Our 4 blogs this week will form the basis of a twitter chat on 12 February at 8pm UK time.  All are welcome – health professionals, service users, carers, parents, and those with multiple roles.  Use #ebnjc to join the conversation.

Historically there have been attempts to integrate mental health within the consciousness of society. Closures of Mental Health Institutions along with the Health and Social Care Act 2012 created a legal responsibility for the NHS to deliver ‘parity of esteem’, meaning people with mental health problems receive the same standard of care as those with physical health problems. We still have a very long way to go to see actual integration and parity of esteem even with the new transformation plans for Child and Adolescent Mental Health Services (CAMHS) set out in the NHS Long Term Plan.

Having worked in CAMHS for many years, it’s my current role as a CAMHS Crisis Liaison Nurse working alongside Paediatric and A&E staff supporting young people presenting in a mental health crisis that has given me insight into how mental health patients experience care and are perceived. I am struck how the young person is in the middle of two different healthcare systems, and this is one of the times they come together to care for them. Or do they? I know nurses, doctors, healthcare assistants all really do care about the young people on their ward. They will get reviewed in ward rounds, be offered to attend the ward school, be fed and watered, will get a bed to sleep in whilst they wait for the “mental health expert” to come, but does anyone actually engage and try to understand them beyond the behaviour and symptoms they present with? You don’t have to be mental health experts to engage on a human level.

On the other side of the fence you have the CAMHS teams unable to respond quickly due to increasing caseloads and reduced capacity. This results in the young person experiencing a disjointed system of care and delay in who takes ‘ownership and responsibility’. That sounds harsh to say, but put yourself in that young person’s shoes, who has been stuck waiting for hours in A&E or the ward, only to experience staff saying – “These mental health patients are bed blocking”, “When will CAMHS come and discharge them” or sometimes even being ignored and then radio silence from CAMHS until the next working day (if they are lucky). These challenges we all experience as a result of years of under funding in CAMHS, pressure on beds and understaffing in the acute trusts. However, there are changes on the horizon within the NHS in CAMHS, some have already started therefore it’s even more important to think about how we keep mental health and physical health services integrated.

Despite these systemic pressures there are lots of positive experiences, including my own. I, with a paediatric nurse colleague, deliver training to acute hospital staff to, myth bust and de-stigmatise young people’s mental health, with the goal to deliver an integrated service, supporting them to feel confident that they are best placed to communicate and engage with the young person in their department, rather than wait for an agency RMN to ‘special them’ who generally has no CAMHS experience. There is real motivation on the part of paediatric staff to feel better equipped in talking to young people with mental health issues and in my area there is definitely increased confidence and engagement. However, this is just the tip of the iceberg in integrating care.

With the proposed developments, it has been pledged in the Long Term Plan to ensure that children and young people can access 24/7 mental health crisis services that combines crisis assessment, brief response and intensive home treatment functions with a range of complementary and alternative crisis services to A&E. Everyone agrees no one should reach crisis point to be able to access care and that young people should be supported, where possible in their own environment but, does this actually create parity of esteem and a more holistic integrated service with physical health colleagues? It does move towards parity of esteem in terms of more money and resources, it’s good for meeting targets and creating evidence base for future investment yet I would argue it creates less integration with our physical health colleagues.

Paediatric colleagues could in turn have less exposure/experience in working with mental health, it could compartmentalise care, and in turn we could be neglecting the young person’s physical health as research shows more than half of mental health problems in adulthood are established before the age of 14 and people who suffer from a mental health problem are more likely to experience chronic physical health problem (Moy, 2009). Therefore integration has to be more than reducing waiting times in A&E, reducing pressures on wards, creating new CAMHS teams or 24/7 CAMHS access.

True integration is about professionals from physical and mental health services being equal stakeholders. This is an ideal but we have to start with the ideal and then work with the limitations of the organisational systems to bring key people from physical and mental health to the table to make mental health everyone’s business.

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