372 Chapter 43
Inclusiveness
Within health care, it is sometimes useful to distinguish between ‘patient-
centred’ and ‘population-centred’ traditions. Most clinicians are firmly
rooted in the patient-centred tradition – they focus on improving the
health of the individual patients who present to their service. By contrast,
the population-centred tradition focuses on the health of the population
as a whole, including individuals who do not present to services. This sort
of ‘public health’ perspective is often particularly relevant to planning. For
example, a CAMHS might provide excellent treatment for children and
adolescents with ADHD, and the clinicians working in the service might
be rightly proud of how satisfied the families are. Unless the service also
takes a population-centred view, they may not realise, for example, that
they are providing this excellent service for just 100 individuals when the
epidemiological data suggest that their catchment area probably contains
around 1,000 children and adolescents with ADHD. What is happening
to the other 900? Perhaps all is well: 600 are being well managed by
family doctors and paediatricians, while the other 300 families have made
a well-informed choice not to seek treatment. In most parts of the world,
however, the reality is less satisfactory: many of the ‘missing’ children
and adolescents are regarded as lazy, stupid or naughty; and even when
parents and teachers suspect ADHD, they have not known how to access
expert assessment and treatment. A British survey that followed up a large
and representative sample of children and adolescents with psychiatric
disorders (see Box 3.1) found that only a quarter of them were seen by
specialist mental health professionals over the following three years, and
although some of the remainder were seen by educational, social or pae-
diatric services, that still left half of them receiving no help at all over the
entire three-year period. This is unacceptable – there is no justification for
neglecting the needs of individuals who have treatable chronic disorders
that seriously undermine their present and future quality of life.
When planning services, it is important to aim for inclusiveness: meet-
ing the mental health needs of all the children and adolescents in the
catchment area whether or not they currently use these services. No
one should be excluded because of their gender, ethnicity, social class,
physical disability or intellectual level. Various barriers may make services
seem inaccessible or unacceptable. For a service to be accessible, families
and referrers have to know the service exists, they have to know what
the service offers, and they have to be able to get there (so location is
important, as is the availability of public transport). Accessibility is greater
when services are open outside 9–5 hours and when there is a creche`
for siblings. The wait for an appointment should not be excessive, and
there needs to be some arrangement for responding rapidly to crises;
some services aim to carry out the initial assessment rapidly in all cases,
though there may then be a waiting list for non-urgent treatment. The
acceptability of a service to families is also influenced by the attitudes of
staff and the physical condition of the building.