Child and adolescent mental health – a guide for healthcare professionals
June 2006
Strategies for improving care (England)
The government has stated that it intends to ensure that every child is able to be healthy, have enjoyment, be able to achieve, and make a positive contribution. [Go to note 88]. A reform of children’s services has been undertaken to achieve these aims. The Children Act, which received royal assent in November 2004, provides the legislative foundation for these reforms. 'Every child matters: Change for children' (2004) sets out a national framework for local change programmes. The reforms focus on all aspects of children’s lives, many of which will impact on mental wellbeing. For example, deprivation can affect the mental health of children, as can poor diet and lack of exercise. [Go to note 36]. See 'Health inequalities' secion for the effects of deprivation, and the 'Problems faced' section for a more detailed discussion on diet, exercise and mental health. In July 2005, the government released 'Youth matters', a consultation document on proposals to improve services and opportunities for teenagers. [Go to note 89]. The 'National service framework for mental health' (1999) (mental health NSF) covers the mental wellbeing of the entire population and includes recommendations for children and young people. [Go to note 90]. The 'National service framework for children, young people and maternity services' (children’s NSF) [Go to note 91] sets out national standards for high-quality health and social care. It is a 10-year programme, launched in September 2004, which forms an integral part of 'Every child matters'. Standard 9 refers specifically to the mental health and psychological wellbeing of children and young people. See appendix 2 for the full list of standards included in the children’s NSF.
The children’s NSF makes the point that supporting children and young people with mental health problems should happen across all services and is not solely the responsibility of dedicated child and adolescent mental health services. Health, education and social services, along with housing, local amenities and the voluntary sector all have a role to play. [Go to note 92]. One of the aims of the reforms is to shift the focus from dealing with the consequences of problems to preventing problems occurring in the first place. There is evidence to confirm that preventive measures are effective, reducing risk factors, strengthening protective factors and decreasing the symptoms and onset of some disorders, especially when targeted at high-risk groups. [Go to note 93]. The importance of intervention at as early a stage as possible has also been recognised. [Go to note 92] For example, the 'Mental health policy implementation guide' sets out guidelines for early intervention in psychosis for 14-35 year olds. Early intervention in psychosis can prevent initial problems, reduces the risk of suicide (one in ten of those with psychosis commit suicide, two thirds of those within the first five years of illness), and improves long-term outcomes. All those aged 14-35 with first presentation of symptoms, or within the first three years of illness, should be treated by early intervention psychosis services [Go to note 94]. As part of 'Every child matters', a common assessment framework has been developed for use by all practitioners working with children. It is a nationally standardised approach to assessing the needs of a child, with the aim of early intervention to prevent problems. It is currently being trialled in selected local areas [Go to note 95], and all LAs are expected to have implemented common assessment frameworks between April 2006 and the end of 2008. [Go to note 96]. See appendix 3 on page 59 for details of the common assessment framework.
The Children Act 2004 sets a requirement for LAs to develop and put in place a children and young people’s plan by April 2006. [Go to note 88]. This will replace a number of existing statutory plans and should cover all local authority services for children, young people and their families. However, plans should also involve health services, youth justice, private, voluntary and community organisations.
The Children’s NSF follows on from 'Improvement, expansion and reform – the next 3 years: priorities and planning framework 2003-06', which sets out national requirements for local planning [Go to note 97]. It includes an expectation that comprehensive mental health services for children and young people should be available in all areas by 2006. Further, CAMHS should be increased by 10 per cent each year according to agreed local priorities.
The government set out a range of initiatives aimed at improving the health of the population in 'Choosing health: making healthy choices easier' (2004). [Go to note 36]. Many of the policies aimed at improving the health of children and young people will impact on their mental as well as physical health; indeed, the paper highlights the fact that good physical health is dependent on emotional wellbeing. It acknowledges the need to provide adequate information to children, taking into account what they want, and developing the competence of those working with them. Examples of initiatives include the 'National Healthy Schools Programme', which aims to improve pupils’ health through both the school environment and education curriculum. See the section here for more information about healthy schools. From 2006, the DH will pilot health services dedicated to young people and designed around their needs. It has pledged to build on 'Every child matters' to ensure that all young people have access to expert advice and relevant support. The 2005 consultation, 'Youth matters', expands on developments aimed at improving the health, including emotional wellbeing, of young people.
The UK government is reviewing current mental health legislation, and has announced its intention to publish a new mental health bill based largely on amendment of the 1983 Mental Health Act. It has stated that it would address safeguards for children treated on the basis of parental consent in the Children Act 1989 and confirmed that children under the Mental Health Act will continue to receive the same safeguards as adults. The European Commission has launched a green paper, 'Promoting the mental health of the population', which it consulted on in early 2006. It outlines the relevance of mental health for some of the EU’s strategic policy objectives, proposes the development of a strategy on mental health at Community-level and identifies possible priorities. It considers children and young people as part of the general population. [Go to note 98].
Many strategies, including the Children Act and Children’s Trusts - read more here - emphasise the importance of developing the participation of children and young people in the health, education and social care services they receive. The value of involving young people in CAMHS is mentioned in the chapter on barriers, read more here, as a means of addressing some of the obstacles young people face in accessing care. For example, it allows young people’s views to be heard, and helps them to feel respected by professionals. YoungMinds has produced 'Putting participation into practice' (2005), which provides guidance for CAMHS practitioners on involving children and young people in service development. [Go to note 99].
Child and Adolescent Mental Health Services (CAMHS)
The term ‘CAMHS’ can be used in two different ways. It can be used to describe all services that contribute to the mental healthcare of children and young people, including health, social care, education and other agencies. The primary function of these services may not be mental healthcare. The term is also used to describe specialist mental health services. The primary function of these services is the delivery of mental healthcare, and such delivery generally occurs through multidisciplinary teams. [Go to notes 7 and 100]
CAMHS are often described as being organised into four tiers:
| Tier 1: | Primary level of care. Includes: GPs; school nurses; teachers; social workers; youth justice workers; and voluntary agencies. |
| Tier 2: | Services provided by specialist individual professionals relating to workers in primary care. Includes: child and adolescent mental health workers; clinical child psychologists; paediatricians; educational psychologists; child and adolescent psychiatrists; child and adolescent psychotherapists; community nurses; and family therapists. |
| Tier 3: | Specialist services for more severe, complex or persistent disorders. |
| Tier 4: | Essential tertiary level services such as day units, highly specialist outpatient teams and inpatient teams. |
Tiers 3 and 4 include: child and adolescent psychiatrists; clinical child psychologists; nurses (community or inpatient); child psychotherapists; occupational therapists; speech and language therapists; art, music and drama therapists; and family therapists. [Go to notes 7 and 101]
This model provides a framework which describes fully comprehensive services. It can however be misleading, as people and services may not fall neatly into one tier. It also implies that the higher up the tier, the more severe the problem, although this is not necessarily the case. Although most children are likely to be seen at tiers 1 and 2, some may enter the system at any point, and will not necessarily move up through the tiers. Services are also commonly described as universal (anyone can access them, ie tier 1), targeted (tiers 2 and 3) and specialist (tier 4).
The provision of comprehensive CAMHS by December 2006 has been set out as a Public Service Agreement (PSA), one of the government’s key priorities [Go to note 95]. It should, however, be noted that the Children’s NSF defines comprehensive CAMHS as: 'in any locality, there is clarity about how the full range of users’ needs are to be met… This will not necessarily mean that all services will be in their final configuration or available in every locality by 2006.' As such, comprehensive services may not be offered in every area, although there is also a requirement to have arrangements in place to ensure a pathway of care, provided through other services [Go to note 7]. In reality this may mean difficult to reach services, with patients having to travel some distance to receive treatment.
The recent policy developments will result in the expansion of CAMHS at a local level, and the government has committed approximately £300 million additional funding to PCTs and LAs for CAMHS development from 2003/04 to 2005/06 [Go to note 36]. It is vital that PCTs use this money and any future funding for CAMHS; it should not be channelled into other services. A team of 12 CAMHS regional development workers has been established to facilitate change in this area [Go to note 88]. To ensure that the PSA target will be met, delivery of CAMHS is being monitored in three key areas:
- 24 hours a day, seven days a week cover
- services for children and young people with learning difficulties
- services for 16 and 17 year olds.95
Since 2002, a national mapping exercise of CAMHS tier 2 to tier 4 has been carried out for the DH. This allows the provision and expansion of services to be monitored and analysed. It also provides information for the Healthcare Commission to assess performance against targets. Detailed information about individual services should therefore be available to inform and support further development of services and the implementation of the children’s NSF. The exercise aims to compile an inventory of all specialist CAMHS (tiers 2-4) in the UK, and the investment that they receive. It also contains commissioning data at PCT and strategic health authority (SHA) level, although it does not currently include services in the private sector [Go to note 62]. The information is collected online, and annual reports can be accessed here at: www.camhsmapping.org.uk.
In 2004, a total of 139 services were mapped giving details of 989 CAMHS teams. The total caseload of services in 2004 was 104,744, which represented an increase of 21 per cent on 2003. Nationally, however, there was considerable variation in provision, and some localities showed negative growth. This is emphasised by ratings awarded by the Healthcare Commission to mental health trusts for increase of CAMHS in 2004-05 compared to 2004-03: 31 per cent of trusts were awarded top marks, but 17 per cent were awarded the lowest, poor rating. This is a relatively high proportion, given that 25 per cent of trusts were not rated due to inapplicable data. [Go to note 105]. The Healthcare Commission has also published star ratings for PCTs and NHS trusts, which showed that approximately 70 per cent of PCTs scored top marks for CAMHS provision in 2004. This is based on an assessment of their increase in investment and the existence of well developed and current needs assessment. [Go to note 106].
CAMHS mapping showed that the total spend in 2003/04 was £340 million, which increased by 23 per cent in 2004-05. [Go to notes 62 and 1]. There were variations in the budgetary increase between SHAs of 11 per cent to 45 per cent. Mainstream funding accounted for 95 per cent of the total CAMHS budget for 2003-04. Other significant sources of revenue came from Sure Start, children’s centres (read more here), the Children’s Fund, and drugs and alcohol, and youth offending funding.
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CAMHS mapping also highlights national variations in the CAMHS workforce. The data are measured as workforce per 100,000 population of 0-17 year olds. While this increased by 15 per cent in 2004 compared to 2003, it varied between an increase of 40 per cent and a decrease of up to 5 per cent. (See appendix 4 here for a list of healthcare professionals included.) The mapping also highlighted a high vacancy rate, which was similar for all professions, but again varied nationally. Vacancy is defined as a funded post which a service is actively seeking to fill. For example, the average vacancy rates for clinical psychologists was 14.8 per cent in 2004. [Go to note 62].
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CAMHS mapping has shown that the number of services available and cases dealt with have increased from 2002. However, the demand for services has grown even faster, evidenced by an increasing number of people waiting for treatment. The mapping found that at the end of the study period, there were 30,716 cases waiting to be seen, compared to 28,880 in 2003 and 21,329 in 2002. As a proportion of active caseloads, these figures represent 29 per cent in 2004, 34 per cent in 2003 and 27 per cent in 2002. The length of wait also increased from 2003 to 2004 [Go to note 62]. A survey published in March 2006 found that many GPs were forced to prescribe antidepressants, against NICE guidelines, as alternative treatment was not available, or waiting lists for psychological therapies were so long. The survey of 1,300 GPs found that the problem was particularly serious in children’s services, with waits of five months for child psychiatrists. The survey also found that the length of wait, and services available vary across different regions. [Go to note 107]. It is clear that while funding and capacity of CAMHS is increasing, in certain areas if not nationally, this increase is insufficient to meet a growing demand for mental health services among children and young people.
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Recommendations
- Government policies and strategies that are currently being implemented, such as Every child matters, Choosing health and the national service frameworks must be fully monitored and data collected and analysed to ensure that they are effective in addressing need. This information should be made publicly available.
- The government must, as a priority, address the current shortage of mental healthcare professionals.
- There must be adequate funding for CAMHS to ensure that they are properly resourced and staffed.
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