On January 22nd I attended a stakeholder event to advertise the 2gether Trust’s Children and Young People Service (CYPS), which replaced the Child and Adolescent Mental Health Service (CAMHS) in April 2011. Stakeholder, in this context, means anyone with any professional interest in the topic, not necessarily with anything at stake. I attended as a governor of 2gether.
Children’s health and maternity services in Gloucestershire are jointly commissioned (that is, jointly contracted and funded) by the NHS Primary Care Trust and the County Council. The Lead Commissioner gave a brief introduction to the event, describing how commissioning work had started in 2009 following a national review of CAMHS, Children and young people in mind.
The event’s main presentation was given by the CYPS Service Director. I thought it was unfortunate that much of what he said seemed a little vague, as if he was just reading someone else’s presentation. For example, under “What we’ve done so far”, one of the bullet points was “Improved performance”, but there was no mention of any data at all behind the claim.
Once or twice the words on the slide didn’t quite match the words the service director spoke. The worst example of this was a bullet point that said “understanding sexual behaviour”, which he read out as “understanding sexualized behaviour”, and didn’t stop to correct. The odd thing is that he was originally a clinician, so he presumably knows that the two words imply different things.
We were told that 2gether’s CYPS is part of a national pilot of Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT). It’s curious and unfortunate that the main CYP IAPT webpage doesn’t describe it as a pilot, and doesn’t mention Gloucestershire in the list of sites. It’s hard to find Gloucestershire on the related MyAPT website, too (not that MyAPT was ever mentioned at the event). 2gether is listed elsewhere in information about CYP IAPT as a member of one of the Year One Learning Collaboratives, of which there were three, increasing to five in year two. Each learning collaborative is led by a university and involves several trusts. 2gether’s is led by Reading University.
I asked about the time scale for seeing formally benchmarked outcomes data published through CYP IAPT but I was disappointed to get only a vague reply.
Listening to local communities
A key document in the handouts was a page headed Listening to our local communities that listed a dozen items of feedback about CAMHS, and outlined how CYPS is an improvement. However, several of the improvements seemed weak.
For example, the very first item in the list is:
“Demand outstrips capacity.”
The response begins:
“There are now more PMHWs [primary mental health workers] allocated to each of the localities…”
However, in later discussion with the service director he mentioned in passing that there are only eleven PMHWs for the entire county. It is not clear, either, whether the unmet demand for CAMHS is met at all by PMHWs, or whether they are addressing (and perhaps even creating) a different demand.
The response continues:
“…we have a complex engagement team and clinicians concentrating on minimising the need for admission.”
It is not at all clear that either of these initiatives satisfies unmet demand. The complex engagement team works with patients who have difficulty engaging with services in the usual way by attending appointments at clinics and so forth. The problem with hospital admission is that Gloucestershire has no inpatient beds for patients under 18, so they have to be sent out of county (for example, to Oxford or Birmingham) and this costs commissioners a lot of money, not to mention causing problems for the patients and their families.
All three parts of the response are repeated in the responses to other items on the list, further weakening the list’s impact.
I have no doubt that all this work being done with children and young people is an excellent idea, but I am unconvinced that it is an entirely genuine response to the concerns that were voiced about CAMHS.
Another example from the list is the item:
“Lack of coordination with local voluntary sector provision.”
The response is:
“We partner with Action for Children in a number of areas of service delivery. We are exploring further partnering with other VCS [voluntary and community sector] organisations.”
The strong implication is that the lack of coordination with local voluntary sector provision remains just as it was back in the days of CAMHS.
Action for Children is a national charity, not a local one, although it did operate to a limited extent in Gloucestershire before it won the county-wide CYPS contract. According to its published accounts for 2012, only 10% of its income is voluntary income, and it openly admits to extensive campaigning activities, meeting both of the criteria for a “fake charity” designation.
Again, I have no doubt that Action for Children has the capability to do valuable work with children and young people, but I am not persuaded that the original concern about CAMHS and the local voluntary sector has really been addressed. Someone at the event tried to raise this issue with the service director, but he seemed to become defensive and dismissed it by saying that Action for Children does operate locally in Gloucestershire.
Children and Young People Board
Another key part of the event was a presentation by young people, members of a service-user group that meets weekly in Gloucester. There’s also a related Children and Young People Board, or maybe the service-user group is the board. I’m unsure. Perhaps I wasn’t paying attention when it was explained, or perhaps there was a leaflet about it that I missed.
Young people are involved in the development of the service in various ways. For example, they have made videos that are on the CYP IAPT channel on YouTube.
Three of the young people presented their own or other young people’s stories as case studies. It was strange that the mild symptoms they described, feeling down or anxious, didn’t match the very long treatment times of between a year and a half and three years that they reported.
One of them, referred to CYPS for anxiety, had even been sent to Oxford for a while as an inpatient. She seemed to have fond memories of it, and regretted not going back. Previously in the event we had been told that CYPS works hard to avoid inpatient stays, so I suppose there must have been a very significant medical reason for her to have been admitted, but she didn’t mention it.
Many young people, and indeed older people too, feel down or anxious at times as part of their normal emotional response to life. I thought it was wrong to give the impression that feeling down or anxious requires long-term treatment, possible medication and possible hospitalization. Either the young people described in the case studies have serious problems that really do require long-term treatment, but they didn’t like to speak about them, or CYPS is failing to treat some very simple emotional disorders adequately, leading to inappropriate long-term dependency on services. Without proper outcome measures, it’s impossible to be sure.
The event ended with group discussions, which allowed us to ask further questions and to give feedback about our experience of CYPS. No one in my group had any direct experience of CYPS, but we asked some questions and the service director came round and did his best to answer some of them. Just as in his presentation, he often seemed a little vague.
For example, one question was whether staff at Rooftop Housing in Gloucestershire were entitled to use 2gether’s Practitioner Advice Line. Although he said yes, he said it in a hesitant way that made it unclear whether the people who staff the advice line know this and would cooperate.
Events like this are always interesting as ways to meet people and find out what’s going on. This one was no exception. It was informal and not too long. I very much value having attended.
As a public relations event for 2gether’s CYPS, however, this event had some failings. The service director came across as an uncharismatic administrator, apparently lacking detailed knowledge of the service. A senior clinician, able to tell stories and display some passion, might have been a better spokesperson.
It seemed odd that Action for Children didn’t get to give a presentation on the part they play in the whole thing.
There’s too little clarity, I thought, over IAPT and what it means for the service. Outcome measures, in particular, should have been on the “What is still to be achieved?” slide at the end of the main presentation, because without them no one can tell whether all this work is doing any good.
The high point of the event was the presentation by young people. The level of involvement of young people in the service is commendable. Yet the message that came across from their presentation raised doubts about the service’s effectiveness. Surely some stories of recovery could have been found, to balance the stories we heard of (hopefully rare) long-term treatment.