Child and Adolescent Mental Health Services (CAMHS) waiting lists are in and out of the news and becoming enough of an issue to repeatedly show up at First Minister’s Questions. The debate, like so many public policy issues, is turning on whether the SNP can claim that they have delivered. They say they have, their opponents say they haven’t.
Before we get into it, it is worth thinking about the Hawthorne effect. This principle tells us that the act of observing something changes the nature of it. And in the world of mental health waiting lists, that couldn’t be truer. The focus on the service and the 18-week target has led to some pretty significant changes in how we respond to the mental health of our children.
The Scottish Government have been shouting from the rooftops that they’re hitting their target of seeing children and young people within 18 weeks. That is genuinely good news, and a testament to the efforts of healthcare professionals who’ve been working to triage referrals and manage risks effectively. Let’s not gloss over the realities of that success – being responsible for deciding which children need seen urgently and which can wait a while is difficult, risk laden, work. For many, that decision can be life changing, and lifesaving. But here’s the catch: the success being lauded by the Scottish Government has also morphed the waiting list into something entirely different—one that leaves some children and families in the lurch.
The number of children on the waiting list, and how long they’ve been there, are statistics, and there are lots of ways to make statistics move up or down. In this case, the obvious assumption is that meeting the target means children are moving through the waiting list more quickly, more families are receiving support, and everyone is having their needs met. A supercharged system, well-resourced to meet demand. That may be the case for some. There is another answer though. You can meet targets without changing the speed or levels of support just by changing the criteria for the children you need to see.
And that brings us to the rub. Across Scotland, children and young people referred for ADHD and autism assessments aren’t on the CAMHS waiting lists anymore (unless their risk is severe enough). They’re sent down another route, which is significantly backed up. In some places the pathway has closed altogether. In this route, families are left waiting for months—sometimes years—for the assessments that often provide much-needed clarity and support. The 18-week target feels very far away for these families.
This issue comes at a time when we’re all feeling the weight of rising distress amongst young people, which can be seen in increased rates of self-harm, anxiety, and school absenteeism. Teachers report far higher levels of dysregulation and school readiness. The statistics are alarming, and they reveal a deeper crisis brewing beneath the surface.
The Scottish Government are correct – the waiting list success is good and they are taking action. Right now, CAMHS is getting a hefty £123.5 million a year. On top of that, there is £16 million given to local authorities for school counselling, focused on secondary schools. These numbers are significant and are facilitating good, essential service provision, but they are addressing only part of the problem and being used to tell only part of the story.
You can see from the funding split that the focus has been on clearing those waitlists, addressing the most significant risk and driving more resources into diagnostics. This has worked for some. But even for those it has helped, the quickest way to move anyone through any system, which is what a focus on a target forces you to do, is to provide an outcome. In this case that outcome is a diagnosis.
For the Scottish Government’s success stories, and indeed their strategy, this opens up another debate. While diagnosis is important, we risk it becoming our only focus. There is a debate going on about the rate of diagnosis and the risk of pathologising human behaviour and experience. We do know that while a diagnosis provides insight, understanding and a better sense of identity, it doesn’t automatically open the floodgates to adequate support. We also know that, from a system perspective, diagnosis is the easier part. Sustainable, holistic, relationship-based support is harder, and lengthier, and more expensive.
Children and families can find that after a diagnosis they’re still grappling with the same challenges day in and day out. This raises a pressing question for all of us: what are our public services and politicians doing to help support a mentally healthy childhood? For we might solve a diagnostic problem and yet not address the need or the experience. That question is one that is beyond the current CAMHS wait time and diagnostic debate, but one that we should also be expecting answers on from our public services and politicians. To balance the figures above, the Scottish Government spends £130million a year on Pupil Equity Funding, which can be used by schools to support broader wellbeing and attainment. Not much more than the cost of CAMHS.
So the questions we need to ask have to be broader than the focus on waitlists and diagnostics. What are we doing to build resilient families? Are we equipping families with the tools to better understand and cope with emotional challenges and mental health issues as they arise throughout childhood? Are we providingsupport early and setting up mental health and wellbeing services in primary schools for children, schools, teachers, and families to help us all handle big emotions? And are we supporting purposeful activities and fostering community initiatives that give kids a sense of belonging through sports, drama, or the arts?
It’s difficult to understand the roots of the current mental health crisis – the impact of screens, inequality and poverty, and the post pandemic malaise are things that many discuss. But looking from the other end of the telescope, we do know the components of good mental health for children and young people. Strong relationships, supportive parenting, family financial stability, and a sense of community are the bedrock of positive wellbeing, and we can focus on these to make a change. Diagnosis can be incredibly important for many, but while we focus on that crisis, we can’t forget to focus on creating an environment where children can truly flourish. We have to do both.
By shifting our gaze from counting waitlist numbers to genuinely supporting children and their families we might just see change and positive, healthy, happy futures for all children and their families.
Fiona McFarlane is Scotland Director for Place2Be, a children’s mental health charity, and is former Head of Policy and Public Affairs at The Promise Scotland.