Everyone wants to sort out child and adolescent mental health services (CAMHS), but where to begin? Mark Brown looks at the way that the web app Doc Ready is being developed to help young people with their journey through mental health services.
‘What can we do about child and adolescent mental health services (CAMHS)?’ is a question that is seldom far from the lips of both those who use these services and those who care about those who use them.
CAMHS are specialist NHS children and young people’s mental health services that exist to treat or support young people up to the age of 18, so cover a window in people’s lives that roughly corresponds to their school years.
Early intervention seems to make political sense. Nip problems in the bud, the logic says. If we get to the root of the problem when they’re young ‘uns having a bad time they won’t grow up to adults having a bad time. As such, CAMHS is the area of mental health care that attracts the most attention from those outside of the mental health world. It presents, in the popular mind, a way of safeguarding opportunity for the future by taking definitive action.
As with many other areas of mental health, CAMHS services across the country often have to cope with rising demand and falling levels of resource.
According to research by YoungMinds released exclusively to ITV News on 27th July 2015 “since George Osborne became chancellor five years ago a total of £85m has been lost from the budgets of mental health trusts and local authorities”. The research, derived from Freedom of Information requests from YoungMinds to 165 Clinical Commissioning Groups, 97 local authorities and 37 mental health trusts, shows 75 per cent of mental health trusts across England froze or cut their budgets between 2013/14 and 2014/15.
Prior to the general election of 2015, then Deputy Prime Minister Nick Clegg announced a commitment to spending £250m a year over the next five year Parliament on CAMHS. The extent to which this commitment is to be honoured is not clear, as the emerging picture seems to point to loses of funding in some areas of activity with ‘new’ money funding new commitments.
What is clear is that each year new young people are referred to CAMHS services and more make the transition from CAMHS services to adult mental health services.
From the outside, it looks like CAMHS is a simple proposition. A one stop shop for young people’s mental health and wellbeing needs. In practice, as with much in mental health, the picture is much more complex. Some young people will be referred to CAMHS services for assessment by their GP. Others may be referred to CAMHS by teachers or school staff, health visitors, school nurses, social workers or youth counselling services. Some of these referrals will be sought by a young person’s parents or carers, other will be deemed necessary by one or more agency involved in the child’s welfare.
At present we don’t ‘know’ exactly how many young people join CAMHS services each year in total. We do know a variety of other things, though, such as extrapolated levels of demand in each CCG area via the National Child and Maternal Health Intelligence Network.
There are NHS CAMHS services, which are providers of CAMHS services, then there are a variety of different ways that CAMHS might be commissioned. Most of these are NHS bodies, but some aren’t. There are also non-NHS providers of of services as part of CAMHS. There is not one standard offer for CAMHS and different young people will access different services based on the challenges they are facing. They might see a number of professionals with a variety of different roles and different professional backgrounds and approaches. Is your head spinning with complexity yet?
Now imagine you are young person trying to access such services. They might be services you have been desperate to access after a long wait. They might be services that you don’t know why you’re accessing, the referral made on your behalf by an organisation that is concerned about your behaviour or welfare. You might have been waiting a long time for an assessment. You might have been waiting even longer for a referral to be accepted by a service provider. Your parents or carers might have explained everything to you or nothing to you. Your parent, parents or carers might not know enough about CAMHS themselves to be able to explain.
If there are two words to describe the experience of moving through CAMHS they could well be ‘confusing’ and worrying’.
Doc Ready repurposed
In contrast to other areas of mental health, there has been a flurry of interest around the potential for internet-enabled devices and apps and software that run upon them to make a real difference to young people’s mental health. This is, in part, based on the misapprehension that the web and mobile devices are more acceptable to young people because they are ‘new’ and that ‘this internet thing’ is what young people want. In practice, the web and portable devices like tablets and smartphones are increasingly accepted as part of the lives of people in England in general.
The lens focusing on prevention in mental health, coupled with the search for new and cost effective solutions to growing demand and dwindling resources, has opened the door for some digital experimentation in the provision of services around mental health to young people that has not been present in services for people accessing adult mental health services.
In 2013 a partnership of Futuregov, Neontribe, Enabled by Design and my own company Social Spider launched Doc Ready, a tiny web app that helps young people get ready to visit their GP for the first time to talk about their mental health difficulties. Funded by the Paul Hamlyn Foundation, Doc Ready was one of the six projects to grow from the Paul Hamlyn / Mental Health Foundation Innovation Labs process.
Doc Ready began as an idea for an app called ‘See it my way’. Coming out of young people’s experiences of GP services, their initial idea was for an app for GPs that would convert young people’s language into GP language. During a second Innovation Lab this became an idea for an app that rather than trying to modify the practice of GPs, which is a difficult task at the best of times, would help young people to prepare what they wanted to talk about before they got to their appointment; maximising the potential of that appointment including the kinds of information a GP would require to understand what the young person in question was understanding.
Now, working with North Staffordshire Combined Healthcare NHS Trust three of the initial Doc Ready partners are talking the Doc Ready approach to helping young people with their passage through CAMHS.
Taking the same principle of putting the power of preparation and knowledge in the hands of young people, this new iteration of Doc Ready, called CAMHS Ready launched this week, will help young people to prepare for their sessions with CAMHS professionals, but will also help them to understand CAMHS and its various structures.
Maintaining the same co-design ethos as the original Doc Ready, this iteration tries to see the journey through CAMHS through eyes of the young people making it and to answer the questions that they might have along the way. As importantly, the opportunity to prepare also offers reassurance in what can often be a bewilderingly arcane set of services.
At present, one of the challenges with providing CAMHS information is that often individual CAMHS services themselves are unsure of the best ways of providing this information; opting for providing large amounts of information without being able to ensure that it is there at the right time for the young person who may require it. Given the level of regional variation and the ways in which the direction of travel for health services will certainly accelerate this variation over the coming five years; attempts at national information about CAMHS tend to be generic and to provide little of the detail that would reassure young people who will have specific worries about specific services they are accessing.
Like Doc Ready, CAMHS Ready provides advice for young people, but also helps them to create a checklist of things they want to talk about at their session. As with Doc Ready, CAMHS Ready is designed to work on phones, tablets and computers. It doesn’t need to be installed on a device because it lives on the internet, making it accessible to any young person at any time as long as they can get an internet connection. Taking a similar focus to Doc Ready, CAMHS ready helps young people feel more prepared and less anxious about visiting, and provides a simple way of getting conversations started open up conversation, helping CAMHS Staff and young people to get the most from their visit.
The partners are seeking other CAMHS services who would like to develop their own version of the app specific to their services, staff and locality.
Given a fairly strong road test of Doc Ready approach (the original app was evaluated by Mindtech at the University of Nottingham), and given its status as a web app rather than a downloaded piece of software which means that there is no messy pushing of updates to individual devices, it seems the idea that began with some young people’s problems with GP consultations might have managed to come up with something that might help in a little way to address a tiny problem that young people who use CAMHS currently have, and which will help those who join CAMHS each year.
Obviously, something like a CAMHS version of Doc Ready can’t solve the challenge of an overall drop in funding from central government for the commissioning of young people’s mental health services. What it can do is help to make sure that the time resources and knowledge resources of CAMHS services can be best deployed for someone who is currently in need of their support by helping them to get what they want and need out of the experience.
I like the Doc Ready approach; not only because I was involved with its development. One app can’t solve everything; but one app can, if you get it right, solve nearly everything about one very small and particular problem.
If we’re having to fight for every contact a young person has with CAMHS; it makes sense to try to make sure that every contact is as useful as it can be.
CAMHS and the network of services it covers are only going to get more complex and more creaky over the next five years. Helping young people to navigate these increasingly complex and stretched services to their best advantage is in everyone’s interest.
Mark Brown is development director of Social Spider CIC. He was involved in the development of the original Doc Ready app. He is @markoneinfour on twitter. Mark is currently running a digital innovation lab around young people’s mental health and wellbeing and on a digital CAMHS project, both in Leeds, although he actually lives in London.