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BMA response to the CAMHS review - Next Steps to Improving the Emotional Well-Being and Mental Health of Children and Young People

Department for Children, Schools and Families
July 2008

The British Medical Association (BMA) is an independent trade union and voluntary professional association which represents doctors from all branches of medicine in the UK. Our response includes input from the relevant BMA committees including the Central Consultants and Specialists Committee’s Paediatrics Subcommittee, the General Practitioners Committee and the Board of Science.

General Comments
The BMA welcomes the opportunity to comment on this document. We recognise that CAMHS have made a significant difference to improvements in services to meet the needs of children and young people who are experiencing mental health problems. In recent years, CAMHS has improved considerably in terms of being comprehensive and linked up.

We would like to draw attention to recent health promotion publications produced by the BMA which focus on the health of children and young people. These include Growing up in Britain (1999), Eating disorders, body image and the media (2000), Adolescent health (2003), Preventing childhood obesity (2005), Childhood and adolescent mental health (2006) and Breaking the cycle of children’s exposure to tobacco smoke (2007).

The BMA’s 2006 report Childhood and adolescent mental health: a guide for health professionals examines the types and prevalence of mental health problems faced by children and young people aged five to seventeen years. The report makes a number of recommendations and these are included below under the questions that they are most relevant to. The BMA report and its recommendations are focused at UK level as opposed to focusing on specific examples at a local level.

Question 7a
Please describe the CAMHS commissioning arrangements in your local areas and your view on the effectiveness of these.

The CAMHS commissioning arrangements vary across the UK. Usually it is separate from commissioning other relevant services, for example, community and hospital paediatrics, school nursing and health visiting. This can lead to duplication and omissions and may prevent ‘joined up thinking’. In areas where multi-agency working is normal practice, this approach makes it difficult to fund and staff multidisciplinary teams, for example, psychological support for long term conditions like cystic fibrosis and learning disability. Children’s Mapping indicates that community paediatrics provide ADHD and ASD services in about 1 in 3 districts. Where they provide one, they usually provide the other. This contribution needs to be taken into account in allocating resources to avoid adverse effects on disability and child public health services.

Question 7b
What would improve them?

Clarity regarding the arrangements and clarity regarding exactly what has been commissioned and what has been provided which can be very different.

Commissioners should be required to recognise CAMHS services as a whole, including contribution from universal and targeted services outside CAHMS specialist services.

Question 8
In your local area, how effective is the promotion of emotional well-being and mental health of children and young people and their families?

There is a need to improve public knowledge and understanding of mental health. There should be better provision and dissemination of information about mental health aimed at children and young people, appropriate to different age ranges. This should include information about what different mental health problems are, how and where to access help and support, what different mental health professionals do, and what treatments entail. Information should be presented in a variety of media that appeal to children and young people, and in different languages.

School nurses and health visitors can provide this kind of information and support to children and young people. However, Children’s Mapping indicates that school nurse numbers are nowhere near the target of 1 per school cluster and health visiting numbers are also well below target. Pressure to implement mass vaccination campaigns and the withdrawal of routine Health visitor contact beyond the first year in many PCTs inevitably impact on the ability of these services to promote emotional well being.

Question 9a
In your local areas, what factors enable the effective promotion of children and young people’s emotional well-being and mental health?

Direct commissioning of health promotion activities, with recognition of its importance are the significant factors. We would also like to promote the ‘invest to save’ approach with prime funding to put health promotion strategies in place before reducing treatment services. Recent emphasis on emotional wellbeing in schools has helped to recognise more children with difficulties, however treatment services are not always equipped to deal with increasing numbers presenting for intervention.

The media should be encouraged to show those with mental health problems in a positive light, including children and young people.

Question 9b
In your local area, what factors hinder the effective promotion of children and young people’s emotional well-being and mental health?

• Budgetary reduction that focus more on preventive services than treatment services.
• Workforce capacity.
• A less cohesive approach with many unco-ordinated initiatives, supported by short term funding, that end when funding ceases as the PCT will not continue it.
• Managing workforce capacity with appropriate skill mix.

Question 9c
In your local area, how can the promotion of children and young people’s emotional well-being and mental health be improved?

There needs to be a firm commitment to the above along with recognition that 20% of children and young people may have emotional issues at some time in their childhood, and a lot of this is unrecognised. We would strongly recommend co-ordinated commissioning that sees problems collectively rather viewing services in isolation.

There is a need for more and better mental health promotion to Black and Minority Ethnic groups in order to address health inequalities.

Current strategies, such as the Department of Health’s Mind out for mental health campaign and the National Institute of Mental Health in England’s strategic paper, From here to equality , which aim to address stigma and discrimination against those with mental health problems must be fully implemented. These strategies should be monitored to ensure that they are adequate and effective.

Question 10a
In your local area, how effective is the prevention of mental health problems for children and young people and their families?

See comments in question 9 above.

Question 10b
In your local area, how can prevention of mental health problems for children and young people and their families be improved?

See comments in question 9 above.

Early identification of emerging issues and early intervention is essential.

Question 11a
In your local area, how effective are strategies of early intervention for children and young people, at risk of, or experiencing mental health problems and for their families?

Early intervention is still severely constrained in some areas. In many areas, paediatricians are filling gaps in specialist CAMHS services. Thus they improve access, but often at the expense of disability and child public health services. In the case of hospital (inpatient) paediatrics, they can be expected to manage self harm and acute mental health crises without adequate mental health support. Some areas still rely on generic psychiatry cover out of hours, with consultant paediatricians seeking advice from psychiatry juniors with little experience of child mental health. Child mental health inpatients, for example, eating disorders or challenging behaviour can be inappropriately accommodated on inpatient paediatric wards, disrupting care for other patients as the wards are not designed to manage this kind of work.

Question 11b
In your local area, how can strategies of early intervention be improved?

Prompt access to expert advice is essential if early intervention is to operate successfully. All areas should have consultant level support (psychiatrist/psychologist) accessible 24/7. In some areas, this may be at regional level.

Where is it agreed that paediatric beds should be used for mental health crisis support, these should be designed and staffed with appropriate skills to manage the problem effectively.

Early intervention is the responsibility of all, not just CAMHS.

Question 12
In your local area, how effective is access to services for children and young people and their families who have concerns about their emotional well-being and mental health?

Access to services varies across the country. Children’s Services Mapping indicates that about 1 in 3 community paediatric services see children with ADHD and ASD. Usually services see both or neither. In some cases, paediatricians have taken a major role in these areas because CAMHS services are still difficult to access. Concerns have been expressed in the past about the training and quality of paediatric input. However, many community paediatricians have had specific training in child mental health and indeed there is now a subspecialty specifically related to this within the paediatric specialties.

Various models have been developed ranging for completely separate services, to close cooperation with CAMHS development money being used to support paediatricians with this kind of work.

Question 13
Have your services established care pathways for children and young people with mental health problems? If so are they useful? If not, do you think they would be useful?

Care pathways are extremely helpful for children with neuro-developmental problems. We are aware of examples around the country with agreed established pathways for ADHD and ASD. However cooperation is variable and some services remain wary of each other. Where cooperation exists it is beneficial and improves access by reducing duplication and clarifying referral routes for referrers.

The new opportunities for co-operation through the Map of Medicine and the Bristol Care Pathway Toolkitare are to be encouraged.

The arbitary demarcations of ages in accessing care should be highlighted. Using the example of an adolescent at age 16, approaching 17, CAMHS services can be less inclined to deliver care as the patient will soon be passing onto adult services. Adult services will not see these patients as they are under 18. Adolscents do not necessarily need complicated team assessments in the style of CAMHS but can be denied simple interventions by the practice based CPNs even though they have left home and are in employment. Thus it is important that all areas have access for adolescents, achieved in many areas by a 16-19 Team bridging the gap between CAMHS and adult services. Transition for those with mental health difficulties should be no different to those with other long term conditions, where transition services are well established e.g. diabetes, cystic fibrosis

Question 14
To what extent do variations in the terminology used across the different professions, that provide services for children and young people with emotional well-being and mental health concerns, affect the way that services are provided? What are the main issues? How can they best be addressed?

The inconsistent terminology and the lack of an evidence base for psychotherapeutic intervention is a major impediment to national service provision.

Question 15
In your local area, how good is the expertise of those working in mainstream/universal services (such as GP surgeries, early years settings, schools) to identify and effectively assess concerns about children and young people’s emotional well-being and mental health?

GPs play a significant role in identifying and managing patients as necessary in primary care. One of the key barriers to referral that GPs face is the perceived lack of local service or strict referral criteria that makes the service too restrictive. Equally, the role of the health visitor working with GPs in primary care cannot be underestimated. A good health visitor service is key in identifying children at risk of developing mental health problems, particularly adjustment reactions often related to dysfunctional families and/or poor parenting through their universal and targeted work. The move from a practice based health visitor service to a geographically based service has been detrimental to the identification and management of such patients in primary care.

HVs were identified as key people in the recognition of ASD in two UK studies in Stafford and Kent. The reduction in universal HV services therefore puts recognition of this group at risk, especially as universal face-to-face contact at 2-3 years has been discontinued in some areas. There is anecdotal evidence that children with behaviour difficulties including ASD are being identified later than before and an audit in one area showed that only 2 of 17 new referrals with ASD came from HVs. We therefore welcome the recent reintroduction of a face-to-face contact at around this age in the new Child Health Promotion Programme.

The plurality of provision in early years, with many independent providers, makes clear pathways difficult to implement.

Assessment is hampered in many areas by lack of resources. An audit of implementation of the National Autism Plan for Children has shown recently that little progress has been made in reducing referral to treat times for ASD. One reason given for the lack of progress is the lack of funding for the Plan compared with other highly successful initiatives in other health areas e.g. implementing the use of statins in adults at risk of coronary heart disease.

Question 16
In your local area, how effective is the expertise of those working in mainstream/universal services (Such as GP surgeries, early years settings, schools), to address concerns about children and young people’s emotional well-being and mental health?

GPs can often confidently deal with many problems in this area, however, they do feel that there is a lack of appropriate and timely support when it is required. HVs and school nurses, when properly trained, supported and resourced can be very effective in addressing concerns in these areas. HVs have been shown to be effective in managing behaviour in young children and can also make a valuable contribution to providing parenting support in groups or with individuals. However, unless cases present early (or can be identified though universal contacts) they can become intractable and then need more expertise and time than primary care services can provide.

Question 17a
In your local area, how well does collaborative/integrated working across agencies work?

We know that cooperation varies across the country. A straw poll at the BACCH annual meeting in 2004 showed:

• About 50% of community paediatric services were already cooperating with CAMHS, meeting regularly, discussing cases and having joint training
• Others had moved on, sharing referrals and seeing cases jointly
• However <10% had paediatricians working within CAMHS

We are aware of some models of working where close cooperation occurs and these should be shared more widely. It is essential that all professionals providing CAMHS receive adequate training and support to enable them to work effectively together. Measures that have already been taken to implement multi-agency working must be continued and extended. Governments need to ensure that the resources, including training in the healthcare information technology system, are available to allow this to happen.

Question 17b
In your local area, what factors support or hinder collaborative/integrated working?

A key factor that needs to be addressed is resource allocation. Where resources are scarce, it tends to hinder collaboration as services compete for the resources that are available. Where community paediatricians provide mental health services, this needs to be taken into account in their resource allocation. Otherwise their work in other areas e.g. disability and child public health is affected.

Where the leaders of both services can cooperate, and where commissioning is done jointly, this promotes collaborative working.

There continues to be a preponderance of the parenting inadequacy model with inadequate recognition of the neuro-developmental basis of many presentations.

Question 17c
In your local area, how can effective practice in collaborative/integrated working be improved?

See a) and b) above.

Question 18
In your local area, how effective is access to training and development opportunities for those working with children and young people to improve the quality of work on emotional well-being and mental health concerns?

Training opportunities for paediatricians and GPs are limited. However good collaborative arrangements exist and should be replicated. We would want to see wider access for GPs and other primary care staff to protected learning time sessions organized by PCOs in the area of child mental health, perhaps with support from paediatric and CAMHS colleagues. It is important that all paediatricians are competent in child mental health issues and these competences have been included in the RCPCH Competency documents for general and community paediatricians. In addition, paediatric trainees can now specialise in children’s mental health.

CAMHS teams should be encouraged to recognise these competences and to support joint training initiatives where these do not already exist.

Question 19a
In your local area, what are the gaps in training and development for professionals working with children and young people at risk of or experiencing emotional well-being or mental health concerns?

Many health professionals struggle to find time and funding for all kinds of training. Mental health training is often not seen as a priority for those not directly concerned with such patients, yet AHPs and nurses will usually have more contact with children with these difficulties more than CAMHS (in the light of the prevalence of these difficulties in children using universal services and the low proportion referred to specialist CAMHS.

Again, we wish to emphasise the importance of a bio-psycho-social model of thinking.

Question 19b
How could these gaps be best addressed?

We would recommend encouraging those managing all children’s services, not just CAMHS, to see mental health and emotional issues as key issues for all universal services. The role of paediatric services in delivering specialist services also needs to be acknowledged and supported.

All stakeholder professionals should come together to agree a common approach.

Question 20a
Thinking about the workforce in your local area, including people who work in health, education and social care across universal, targeted and specialist services, what do you think are the current issues (for example, capacity, training, joined-up working, mix of different professionals)?

The provision of mental health services to looked after children and young people must be improved. CAMHS professionals and registered carers need training in order to support these groups in their particular needs.

Capacity and access to CAMHS services needs to be improved. CAMHS services can take time to assess patients before offering a service (especially groups for parenting, ADHD and ASD). Access to Learning Disability services still vary, with paediatricians filling the gap. This may include prescribing medications with which they are unfamiliar. In some cases, e.g. Thames area, informal support groups have developed to support paediatricians using psychopharmacological drugs. This model of collaboration and support should be considered elsewhere and accepted as part of responsible prescribing, with protected time for it (as, for example, time for MDT work in cancer services is also protected).

There are also particular access problems for children from ethnic minorities, and for those who may not be literate or speak English.

Question 20b
How can current issues be addressed? What steps should be taken at national, regional, local level?

The government must address the current shortage of mental healthcare professionals. There must be adequate funding for CAMHS to ensure that they are properly resourced and staffed. All child psychiatrists and mental health professionals must have training in child health.

Avoiding duplication, and encouraging cooperation could increase capacity. However, it is likely that further resources will be needed in the most deprived areas and where need is high e.g. those receiving large numbers of asylum seekers.

Moving health visitors back into GP practices, rather than providing the service geographically, would also enable far greater co-operation and thereby speedier management and referral. Some areas have managed geographical working with GP attachment with good effect. This can enhance work with Children’s Centres, while maintaining close working relationships with GP practices.

Innovative services are needed to meet the needs of young people, and access to such services must be improved. Examples include a range of venues that differ from the traditional clinical setting, and easy access to a mixture of services.

Question 21
What have been the strengths and weaknesses in current funding arrangements for CAMHS?

21a Strengths

• Ringfenced resources
• Agreed quality standards
• Central monitoring of both the above

21b Weaknesses

• Considering only specialist CAMHS services, not all CAMHS providers
• Failing to consider the contribution of others outside specialist services as part of the ‘comprehensive’ service i.e. only looking at ‘comprehensive’ within specialist CAMHS

Due to a lack of ‘joined up’ thinking, reductions in health visiting and school nursing services have occurred to the detriment of children and parents while funding an increase in specialist CAMHS services. This approach may, in fact, be leading to a perverse incentive, with an increase of secondary care involvement in simple problems more efficiently managed in primary care.

Question 22
How do you think resources could be used more effectively at local, regional and national level? What kind of investment offers best value for money in terms of improving the outcomes for children and young people?

Local: it is important to ensure that enough resources are directed to primary care through commissioning.

Regional: there needs to be a greater emphasise on commissioning enough inpatient facilities to ensure care closer to home for those needing inpatient care.

National: the CAMHS area should be perceived as including other related areas especially health visiting, school nursing and paediatrics. Steps should be taken to ensure that commissioning at local, regional and national level uses ‘joined up thinking’ to avoid perverse incentives.

Question 23
Are mechanisms in place to assess outcomes and the impact of services provided for children, young people and their families?
How can they be improved?

Community paediatricians are working with the Healthcare Commission and the DH to consider quality measures for services for children outside hospitals. It is currently not possible to measure outputs or outcomes for child mental health (though the Mapping exercise measures outputs for 1 month per year). CAMHS, paediatricians and GPs should work together to develop such outcome measures. This work is unlikely to be able to proceed without central recognition and funding as many practitioners are already fully committed to supporting clinical services.

Question 24b
What are the limitations of current performance management arrangements?

The presence of several different managements makes it difficult to monitor/analyse what happens nationally. Separation of CAMHS into mental health Trusts has increased the distance from paediatricians in some cases. There is a lack of accountability for specifying and implementing management plans.

Question 24c
How can performance management arrangements be improved?

See 23c above.

Question 25a
Within your local area, how have service improvements in CAHMS and change in practice been implemented?

They vary according to area: some CAMHS have worked collaboratively with their local paediatricians, even funding more paediatric time in some places, to develop a truly comprehensive service. In others, new funding has been kept in CAMHS, even when paediatricians have seen their referrals for ADHD and other problems increase with little or no increase in funding.

Question 24b
How successful has this been?

Success has been variable as described above in 25 a).

In some areas it is unclear how service improvements have been implemented to the extent there is widespread dissatisfaction.

Question 25c
What factors helped the process?

The open attitude of CAMHS and PCT managers.

Question 25d
Narrow focus on specialist CAMHS, while not considering whole health economy demands.

Question 25e
How can change be implemented successfully?

CAMHS must become fit for purpose by being held to be more accountable.

Question 26b
Are you aware of any examples of good and innovative practice in the area of supporting children and young people with mental health problems?
Can you describe this practice?

• Collaboration between CAMHS and community paediatricians in Huntingdon
• Support for Looked After Children in many areas including Wirral
• Cooperation between CAMHS and Social Services in Wirral
• Psychology support for paediatric services in Northampton

Question 26c
And what, in your view, has enabled this practice to develop?

See 25c above

Question 26d
Yes, if services are willing to adopt a more open attitude and funding is available.

Question 26e
A better understanding of children’s health and developmental needs.

Question 27a
What in your view, is working well nationally and/or locally to provide high quality interventions and achieve good outcomes for those children and young people experiencing mental health problems and their families?

See 26b above.

Nationally and locally the voluntary sector play an important and objective role.

Question 27b
What factors enable children and young people with mental health problems to achieve good outcomes?

• Accessible services
• Problem/solution focussed
• Using evidence-based intervention where possible
• Using groups where possible

An example of good practice from the Buckinghamshire area was a weekly ‘drop in clinic’ run by the child psychology service which HVs could access directly for parents struggling with behavioural management problems and concerns about whether the child had a florid mental illness. Children were screened and if low key, interventions which could be supported by HVs were implemented and the child remained in primary care. If more detailed assessment or therapy was needed the child entered the secondary care service. This service has since been withdrawn through reductions in the HV service. Community services are often seen as a ‘soft’ target for service reductions when money is scarce, compounding the problem of access to reliable good quality care.

Question 27c
What factors hinder children and young people with mental health problems from achieving good outcomes?

• Inaccessible services e.g. long waiting times, several ‘hurdles’ before an appt is offered
• Treatment offered based on what’s available rather than client’s choice
• Culture and environment in which they live are major determinants

Question 28
Do you have any further comments?

The current inadequacy of mental health services for children and young people with learning disabilities must be addressed.

The reforms outlined in the Child Poverty Review must be implemented to end deprivation and therefore reduce risk factors for mental health problems.

Current inequalities in mental healthcare experienced by BME groups must be tackled:

• Initiatives set out by NIMHE and DH must be properly implemented
• Healthcare professionals and providers of CAHMS should receive training in cultural values and beliefs, to enable them to care for children and young people from BME backgrounds more effectively
• Language translation services must be available
• Racism within mental health services must be tackled and eliminated

Barriers to receiving healthcare faced by asylum seeker and refugee children must be addressed.

Actions must be taken to improve access to mental health services in young offender institutions and to tackle the high rate of suicide among young offenders.

In addition to the above, CAMHS in Northern Ireland must be reformed and modernized, in line with current policy recommendations, to address gaps in provision.

The provision of appropriate mental health services to 16 and 17 year olds must be improved. Young people should not be receiving adult care when they are not mature enough to do so. CAMHS should be extended to encompass this age group in all areas.

Collaboration between CAMHS and AMHS must continue and improve to ensure a smooth transition to adult services.