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Adding insult to injury

A community-based support service that would have helped survivors of the Grenfell Tower disaster has been axed owing to funding pressures leaving the long-term well-being of those affected in jeopardy. Keith Cooper reports

'MST is like a licence for how to drive your family and children in the right way,’ says George Zidane*, a minicab driver, from his armchair in his west London flat.

He’s talking about multisystemic therapy, a support service for young people for what is medically termed ‘conduct disorder’ or, more roughly, anti-social or bad behaviour.

Developed in the USA, then rolled out across Europe, MST keeps adolescents out of care and prison, and prevents exclusion from school, so easing and preventing mental ill health further down the line. But its future is now under threat by NHS cuts.

Mr Zidane and his wife, Linda, credit MST with keeping their family together (see ‘MST taught us how to work together’ below). But much to their dismay – and that of mental health professionals who helped them – it’s become the latest casualty of NHS cutbacks and at a time when it is most needed. And it’s not the only one closed for funding pressures.

Their family had been helped by an MST service provided by CNWL (Central and North West London NHS Foundation Trust), which previously served Westminster, Hammersmith and Fulham, and Kensington and Chelsea. But in April last year, it closed after its three CCG (clinical commissioning group) funders turned off the tap, despite the three boroughs there agreeing to foot half of the bill.

Its closure couldn’t have happened at a worse time. Although the CCGs couldn’t have foreseen it, months later Grenfell Tower caught fire, killing 72 and leaving hundreds of families homeless and traumatised.


Knock-on effects

The effect of disasters on communities can be compared to a ‘stone falling in a pond’, according to Kensington and Chelsea papers on the effects of Grenfell. There’s the initial ‘loss and displacement’, then ripples, so-called ‘secondary consequences’ on employment, children’s education and family lives and so on.

A Grenfell trauma service set up at CNWL is already helping large numbers cope with the immediate effects. But different sorts of services will be needed for those later ripples – and MST would have been one, if it hadn’t been shut.

‘To say I’m grieved that MST has gone is probably too strong,’ says Jai Adhyaru, the counselling psychologist who leads the Grenfell trauma service for children and young people, and had set up and run the tri-borough MST service.

‘But Grenfell really needs something like it. It works across systems, bridging the gaps between parents, schools, and families.’

Not having the service has highlighted the gap in service provision during the Grenfell response, Dr Adhyaru adds.

‘This is a time when an intensive, home-based service, available to families 24/7 would have provided much community-based support. Now the service has been disbanded, it’s much harder and more expensive to set it up again from scratch despite the demand and need for it.’

The effect of the Grenfell Tower fire is ‘very significant’ on children, according to the Kensington and Chelsea impact papers. Many who survived are still stuck in hotels. Schools will long be neighbours to the tower’s charred remains. Children at 50 schools, in and around the borough, have experienced ‘some level of bereavement and/or displacement’. Far higher numbers witnessed the fire, or lost friends.

Such traumatic experiences are known to make sleeping, and concentration in class, difficult. Parents’ mental health also suffers.


Classroom disruption

Studies following Hurricane Katrina in the USA found a heightened risk of behavioural difficulties and school exclusions in children displaced by that disaster. In Kensington and Chelsea, residents are already worried about ‘the level of mental health support some children and young people are receiving’ and that ‘poor mental health will manifest in behavioural challenges in school’, the council papers state.

BMA consultants committee deputy chair Gary Wannan, who is also a consultant child and adolescent psychiatrist at CWNL, is furious at the loss of the MST service and the failure to replace it, more than a year on from the Grenfell fire.

‘It’s beyond belief that the NHS fails to grasp the mental health benefits of tackling the behavioural difficulties and resulting social exclusion which so often blights their lives,’ he says.

‘Child and adolescent mental health services across the UK were buckling under the pressures of demands before the Grenfell fire. The evidence shows that MST can help turn that tap down.’

North West London Collaboration of Clinical Commissioning Groups, representing the three CCGs, says it ‘was not possible to prioritise funding for the MST services’ because of ‘ongoing budget pressures on health budgets’.

It claims ‘there was no discernible impact on health outcomes for young people as a result of the MST service de-commissioning’ as it ‘did not directly address health needs for young people’. The service had only helped a ‘very small number’ of families at a cost of £400,000 a year, a spokesperson adds.

This claim of ‘no discernible impact on health’ appears contradicted by a review of the service seen by BMA News.


Violence reduced

An analysis of four years of data found ‘statistically significant improvements’ for children and their primary caregivers. The round-the-clock access reduced inpatient admissions and scored highly in evaluations for access, operational effectiveness, value for money and ‘stakeholder satisfaction’.

One child, under the care of psychiatrists for years, including as an inpatient, was discharged from NHS care after five months of MST. She’d previously been violent to her mother, self-harmed and threatened to kill herself but is now back in education, in a drama club, and has a ‘robust relationship’ with her family.

The CNWL service was one of 30 across the UK, according to MST-UK, their umbrella body. MST-UK national programme lead Cathy James confirmed others had closed owing to funding pressures but that some in Leeds and Leicester had expanded because of their ‘cost-effectiveness’.

MST, as an intervention, had also been given top ranking in a review by the Early Intervention Foundation, one of the Government’s so-called ‘what works’ centres.

However, one recent study in The Lancet, led by University College London professor of psychoanalysis Peter Fonagy, did find that MST was ‘not superior to management as usual’ on some measures. But it also found that parents believed MST ‘brought about more rapid and effective change’.

Ms James says the Fonagy study shows MST was ‘slightly cheaper than management as usual’.

Its findings used referrals, dating back to 2010, she adds, and ‘the quality of implementation of MST has improved significantly since’.

Professor Fonagy tells BMA News ‘it was not justified’ to claim there was no health benefit from MST. It had led to improved and better integrated care for young people with complex behavioural problems which might suffer if CCGs shut them down, he adds.

Dr Wannan agrees the intensive nature of the service makes it look expensive but that the benefits to the mental health of children and adolescents were proven to be significant and some may only be seen long-term.

‘With referrals and demand for mental healthcare increasing, the NHS cannot afford to cut services which are proven to keep families together and young people from disappearing down self-destructive paths into prison and social exclusion, often in the most difficult of circumstances,’ he says.


‘MST taught us how to work together’

David*, son of the Zidanes, had been at high risk of being taken into care by social services.

His mother was called into the school, after he reported her to his teachers.

‘I was dizzy. I was looking all around me. What have I done?,’ she says. ‘People must think I’m the most terrible mother in the world.’

Mr Zidane admits he couldn’t control his son or ‘his anger’. ‘It really made me cry, he was only 11 years old.’

So into their lives came an MST worker, ‘Patrick’.

‘He was like a mum to the family,’ says Mr Zidane. He came around three times a week for eight months. ‘Our son wasn’t listening to us at all, he just prodded and pushed to make us angry,’ his mother says.

The MST sessions were ‘like lessons’ she adds. ‘It taught us how to improve, how to work together.

‘They change the parents and the children and that’s what we needed. It has changed our lives.’

The Zidanes still rely on the things they learned from Patrick.

‘Even yesterday, my son was saying, “breathe in and out, in and out, mummy, breathe like Patrick said”. His behaviour remains challenging at times.

‘We might need MST again,’ she adds. ‘It did a great job, it’s so sad that it’s gone.’

Dr Wannan says the extended and intensive support of MST helps break patterns of behaviour.

‘Because it is intensive, it allows our habits to change,’ he adds. ‘It is also one of the reasons that it looks expensive. But to me, it is good value because of how much better David will do in life.’

* All names have been changed

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