Child and Adolescent Mental Health Services

John Pugh Excerpts

Wednesday 7th July 2010 Westminster Hall

[Jonathan Reynolds]

I am grateful to the hon. Lady for her intervention, and I acknowledge her work and expertise in this field. I approach this subject primarily as a parent, so I am happy to say that more needs to be done. I am not making this a party political issue between this Government and the previous one. I am trying to highlight the issue and, I hope, move forward together, across the House.

I wish to identify some good practice relating to the hon. Lady’s question. Dudley primary care trust operates an autism clinic that focuses on diagnosis and assessment, and has the specialist expertise to assess complex autism cases. The clinic takes a “broad apprenticeship” approach to training new staff, which gives them the opportunity to observe specialists and more experienced clinicians assessing children from behind a one-way mirror.

After new staff have watched several assessments, they progress to shadowing colleagues and then to taking the lead with children with autism, with support from a specialist. Finally, they are able to work alone and train new starters themselves. They learn through practical experience, rather than theory. The clinic also shares its expertise more widely and trains external agencies. For instance, it trained a group of specialist autism teachers and key workers to provide social skills training to children, meaning that social skills training could continue once a child had left CAMHS, making it far more effective than if it had been delivered once and then discontinued.

There is clear evidence that a good understanding of autism is vital to delivering an effective service to the high number of children with autism in the CAMHS system. All professionals working in CAMHS must have their training needs relating to autism recognised and addressed. In “Fulfilling and rewarding lives”, the Government’s recently published strategy for adults with autism, there is a commitment for

“all NHS practitioners”

to

“be able to identify potential signs of autism, so they can refer for clinical diagnosis if necessary… but more importantly so they can understand how to adapt their behaviour, and particularly their communication, when a patient either has been diagnosed with autism or displays these signs.”

The same strategy commits the Government to working with the General Medical Council and various professional bodies

“to improve the quality of autism awareness training in their curricula.”

What action do the Government intend to take to ensure that the NHS training objectives made in the autism strategy, “Fulfilling and rewarding lives”, are met, so that all CAMHS practitioners receive some basic training in autism?

[Dr John Pugh (Southport) (LD)]

The hon. Gentleman has made two distinct points so far: that mental health problems can be masked by autism so that a person who really has mental health problems may be seen only as having autism, and that autistic behaviour can be misdiagnosed as a mental health issue. Surely that is a very tricky situation for any diagnostician to be in.

[Jonathan Reynolds]

Yes, it is difficult. To be clear, my point is that the prevalence and frequency of co-occurring mental health problems with autism require CAMHS professionals to have specialist training. Without that support, there can be misdiagnosis, which can lead to the situation that the hon. Gentleman referred to.

Does the Minister agree that, given the high proportion of children with autism who access CAMHS, all CAMHS professionals should receive some autism training?

I have explained how a basic knowledge of autism among all CAMHS staff is essential to ensuring that appropriate interventions are delivered to children with autism, but that alone is not enough. Providing mental health support to a child with autism is a specialist skill. Research has found that when an autism specialist has been involved in the support of a child, the outcomes and service satisfaction both improve dramatically.

The NAS found that parents who reported that their child had received support from a professional specialising in autism were twice as likely as those whose children had not to agree that CAMHS had improved their child’s mental health. They were also four times as likely to say that a good understanding of autism by mental health professionals had positively influenced their child’s mental health. However, only two in five parents say that their child has had such support.

--- Later in debate ---

[Dr John Pugh (Southport) (LD)]

I want to add a few footnotes to the excellent introduction to the debate by the hon. Member for Stalybridge and Hyde (Jonathan Reynolds), who set out the major issues carefully and meticulously. Mental health and autism cropped up emphatically in debates on the Mental Health Act 2007. We were then largely concerned with the treatment of young people, including making treatment specific to them, rather than putting young people into adult accommodation or the like, or giving them adult services when juvenile services would be appropriate. While recognising that that was not always possible, I pay tribute to the campaign by YoungMinds for adolescents to receive adequate, full treatment no matter what their condition or mental health.

I pay tribute to the work done on the 2007 Act by the hon. Member for East Worthing and Shoreham (Tim Loughton), who has gone on to greater things, and to Baroness Browning, the former Member for Tiverton and Honiton, who was a champion of autistic people in this place and who pioneered the work that was taken on by other hands as the basis for the private Member’s Bill that subsequently became the Autism Act 2009. Off the back of the 2007 Act, I carried out my own research on provision for children and adolescents and wrote to every PCT for which I could obtain a name. I wanted to focus particularly on adolescent mental health provision, rather than childhood provision, and on waiting times. I accept the point that all the hon. Members who have spoken have made about the critical nature for families and, obviously, patients, of waiting times—the time between a suspicion that something is wrong and getting a diagnosis and treatment. Those are of course different things—one can get an early diagnosis but be slow in getting treatment.

It is not surprising that that issue is crucial during adolescence, when huge hormonal, physiological, social and personality changes are happening. That is a stage in life when, often, psychotic and other disturbances first become evident. One of the more depressing passages included in the Library debate pack deals with that fact. It states:

“Mental illnesses are the chronic diseases of young people.”

It continues:

“It is a curious paradox that better physical health in young people has been accompanied by steadily worsening mental health.”

That is indeed what the national statistics show, and it is why early intervention matters, because if it is successful and efficacious it means someone does not have a life of ongoing suffering and disturbances.

My inquiries of the various PCTs unsurprisingly produced patchy results, in accordance with the well-documented contributions made by other hon. Members. There was a general variation in standards, which I think people might expect, and which has been vouched for today, but what disturbed me more was the lack of clarity about who was responsible for the standards. My inquiries were passed from PCT to CAMHS and back. People did not seem clear about who would carry the can if provision were less than adequate. The implication is that for people using the services no one is ultimately responsible; that is the nagging feeling.

Another feature that cropped up in my research was an apparent lack of dedicated facilities and expertise in many places, and a recognition that although in some places there were adequate facilities for children, facilities for adolescents were wholly inadequate. There is no excuse for that state of affairs in relation to Asperger’s syndrome and the autistic spectrum, because what is required for progress is very clear. Certainly, early diagnosis is required, but the National Audit Office report that I have seen—which I think Baroness Browning did something to trigger—clearly stated that specialist autism teams were the way forward, coupled with good integration, and so on. That is all known, but hon. Members have reported that across the country none of it has been perfectly accomplished.

May I make a personal constituency point? I increasingly receive complaints from parents of children who are mildly autistic but are now being excluded from services because needs must—there are pressures on local authority resources, as the right hon. Member for Oxford East (Mr Smith) illustrated. That is profoundly depressing, because the result is that people who could progress to independence and, in later life, manage far better for themselves and not become problems as adults are not making progress at the key point at which they could be making the progress necessary to become independent of parents and institutions.

My conclusion and, I think, the conclusion of the whole debate is that we are confronted with a situation in which there is a known complaint, a known solution, enormous support from the voluntary sector and clarity about what is required, but on the statutory side there is a somewhat ham-fisted response. Getting that ham-fisted response removed and replaced with something better is the thrust of the debate.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

I congratulate the hon. Member for Stalybridge and Hyde (Jonathan Reynolds) on securing both this debate and his seat. The subject is of huge importance to him, and he brought with him his invaluable personal experience, as indeed did the hon. Member for Manchester, Withington (Mr Leech) and my hon. Friend the Member for South Swindon (Mr Buckland). Those personal experiences are crucial to the debate, as are the contributions from those who are experienced in the provision of services. This debate is vital, and I will ensure that all the representations that have been made today are fed back into the policy process. Time is short, but I will just say to the hon. Member for Worsley and Eccles South (Barbara Keeley), who speaks for the Opposition, that some of us were fortunate enough to have listened to and participated in debates on the Autism Act 2009, promoted by my right hon. Friend the Member for Chesham and Amersham (Mrs Gillan), as it made its passage through the previous Parliament. At the time, there was an increasing dislike of and disillusionment with politicians, so I mention that measure because it showed this place in its very best light. It was about cross-party working and building a consensus. It was a genuine attempt by Members from all parts of the House to work together to improve the lives of others—in this instance it was the lives of those with autism. I pay tribute to Angela Browning, the former Member for Tiverton and Honiton, who was sometimes a lone voice calling for services for people with autism. She, too, brought her own personal experiences to the debate thereby helping to raise us to the next level.

I echo the comments made by the Minister of State, Department of Health, my hon. Friend the. Member for Sutton and Cheam (Mr Burstow), at the recent National Autistic Society reception. He said that the standards of care highlighted by the society in its “You Need to Know” report are unacceptable. He was grateful to the society—as indeed we all are—for its tireless campaigning, and was struck by the particular contribution of the young campaigners group. I am sure that he would pay tribute to them were he able to be here today.

The coalition’s programme for government makes it clear that we are committed to supporting the most vulnerable and to tackling health inequalities. There is strong consensus on what needs to be done to improve the emotional well-being and mental health of children and young people. More work is needed on prevention, early diagnosis and early intervention. Those are the key things that are needed by people with autism and mental health problems. We need better integrated working and more evidence-based approaches. The work force must be developed, and, crucially, we must do more to tackle stigma for people not only with autism but with mental ill health.

The National Advisory Council for Children’s Mental Health and Emotional Wellbeing report earlier this year reinforced the scale of that challenge. It called for action to strengthen leadership, build a confident and skilled work force, improve commissioning and ensure real participation by children and young people in service development. For me, commissioning is a vital part of that. It has never been done that well, but there is a general acceptance of the fact that if we improve commissioning, the services will then follow. As has been mentioned during this debate, there are examples of best practice, which we need to be able to transport to other areas. We need to consider all those issues to get the services that we want.

The Government have also promised to deliver measures in “Fulfilling and rewarding lives: the strategy for adults with autism in England”. There are many areas in which improvement in adult autism services will yield benefits for children’s services, such as developing local autism teams, improving access to diagnosis, better planning and better commissioning of services. As several hon. Members have said, raising awareness of the issue and improving skills in the work force should go much wider than just those working in the autism field, and should include teachers and sports clubs and all those who are involved with young people.

Our focus must be on improving the quality of services that we provide to all children. We must ensure that no one suffers the indignities and difficulties that are sadly all too common. I am referring to the frightened young person who is restrained by police because crisis services were not available; the child who feels isolated and frustrated, only to find that health care staff are not trained to help or able to understand them; the parents who desperately want to see an improvement but feel let down by services that do not treat their children as people with individual needs; and parents who are desperate, isolated and at the end of their tether. That is why it is so important to improve the standard of care across the board.

We must plan and build on the work that has been done on integrating services so that local partnerships can work together to deliver what we want. It will require incredible commitment from local NHS providers to engage with the work force to resolve difficult issues such as training and service design. Improving the reach and quality of child and adolescent mental health care means looking carefully at the different services that make up the whole picture. I am referring to universal services that play a pivotal role in promotion for all children and young people; targeted services that provide early interventions for vulnerable children and young people; and specialist services, which the hon. Member for Stalybridge and Hyde mentioned, for young people with complex, severe or persistent needs.

[Dr Pugh]

rose—

[Anne Milton]

I am sorry, there is no time. I already have far too many questions to answer. If hon. Members feel that their questions have not be answered or addressed, I urge them to write to me and I will make sure that we respond.