Child and adolescent mental health services

Review of CAMHS and Government response published (18 November 2008)
The final report of the CAMHS review and the Government's initial response have been published. To find out more, and access the documents, go to the DCSF Review of CAMHS page. 

Further information is also available on this site on the Review of CAMHS page

Child and adolescent mental health services (CAMHS) promote the mental health and psychological wellbeing of children and young people, and provide high quality, multidisciplinary mental health services to all children and young people with mental health problems and disorders to ensure effective assessment, treatment and support, for them and their families.

Context

The term CAMHS tends to be used in two different ways. It is commonly used as a broad concept that embraces all those services that contribute to the mental health care of children and young people, whether provided by health, education, social services or other agencies.

As well as specialist services, this definition also includes universal services whose primary function is not mental health care, such as GPs and schools. This explicitly acknowledges that supporting children and young people with mental health problems is not the responsibility of specialist services alone.

However, the term is sometimes used more narrowly to refer only to specialist child and adolescent mental health services (in other words, services operating at Tiers 2, 3 and 4 of the four-tier strategic framework - see below).

What do they do?

CAMHS delivers services in line with a four-tier strategic framework which is now widely accepted as the basis for planning, commissioning and delivering services. Although there is some variation in the way the framework has been developed and applied across the country, it has created a common language for describing and commissioning services.

Most children and young people with mental health problems will be seen at Tiers 1 and 2. However, it is important to bear in mind that neither services nor people fall neatly into tiers. Many practitioners work in both Tier 2 and Tier 3 services, for example.

Similarly, there is often a misconception that a child or young person will move up through the tiers as their condition is recognised as more complex. In reality, some children require services from a number (or even all) of the tiers at the same time.

The model is not intended as a template that must be applied rigidly, but rather as a conceptual framework for ensuring that a comprehensive range of services is commissioned and available to meet all the mental health needs of children and young people in an area, with clear referral routes between tiers.

• Tier 1
  CAMHS at this level are provided by practitioners who are not mental health specialists working in universal services; this includes GPs, health visitors, school nurses, teachers, social workers, youth justice workers, voluntary agencies.
  
  Practitioners will be able to offer general advice and treatment for less severe problems, contribute towards mental health promotion, identify problems early in their development, and refer to more specialist services.

• Tier 2
  Practitioners at this level tend to be CAMHS specialists working in community and primary care settings in a uni-disciplinary way (although many will also work as part of Tier 3 services).
  
  For example, this can include primary mental health workers, psychologists and counsellors working in GP practices, paediatric clinics, schools and youth services.
  
  Practitioners offer consultation to families and other practitioners, outreach to identify severe or complex needs which require more specialist interventions, assessment (which may lead to treatment at a different tier), and training to practitioners at Tier 1.

• Tier 3
  This is usually a multi-disciplinary team or service working in a community mental health clinic or child psychiatry outpatient service, providing a specialised service for children and young people with more severe, complex and persistent disorders.
  
  Team members are likely to include child and adolescent psychiatrists, social workers, clinical psychologists, community psychiatric nurses, child psychotherapists, occupational therapists, art, music and drama therapists.

• Tier 4
  These are essential tertiary level services for children and young people with the most serious problems, such as day units, highly specialised outpatient teams and in-patient units. These can include secure forensic adolescent units, eating disorders units, specialist neuro-psychiatric teams, and other specialist teams (for children who have been sexually abused, for example), usually serving more than one district or region.
  
  Practitioners working in CAMHS will be employed by a range of agencies. Many (but not all) of those working at Tier 1, for example, will be employed directly by the PCT or the local authority.
  
  CAMHS specialists working at Tier 2 are less likely to be working for the PCT (although some of them might be), and more likely to be working for another NHS trust (or the local authorities in the case of educational psychologists).
  
  Most practitioners working in the more specialised services at Tiers 3 and 4 will usually be working for other types of NHS trust (such as mental health trusts, acute trusts or care trusts, for example).
  
  Clear supervisory arrangements and structures should be in place to ensure accountable and safe service delivery.
  
  Where service delivery demands effective partnerships between agencies (e.g. children and young people with complex, persistent and severe behavioural disorders) joint protocols should be agreed at senior officer level between the NHS, social services and education.

How are they structured?

Because services that contribute towards the mental health and psychological wellbeing of children are provided by so many agencies, including universal services, the effective commissioning of CAMHS is inescapably a multi-agency activity. Primary Care Trusts and local authorities must ensure that an effective commissioning strategy is in place to ensure the provision of comprehensive CAMHS.

There should be full participation and ownership of the process by health, social services and education, and other key partners such as youth justice. In order to provide adequate support to universal services (Tier 1) and to prevent unnecessary admissions to Tier 4 services, commissioners need to pay particular attention needs to be paid to the capacity of Tier 3 services.

The commissioning strategy should be informed by a multi-agency assessment of need that is updated regularly.

As well as locally adjusted epidemiological information, a needs assessment will include an audit of all local services that address mental children's health needs directly and indirectly, an analysis of current service usage, and the views of all stakeholders, including children, young people and their families.

For highly specialised services (such as many of those at Tier 4), collaborative commissioning arrangements between PCTs need to be established; strategic health authorities oversee and performance manage these arrangements. (The only services currently commissioned at a national level are those for forensic secure inpatient provision, and highly specialised inpatient provision for deaf children and young people with mental disorders.)

How does the Children's NSF fit in? The National Service Framework for Children, Young People and Maternity Services (the Children's NSF) is the government's 10-year programme (launched in September 2004) to stimulate long-term and sustained improvement in children's health, by setting standards for high quality integrated health and social care for children from before birth right through to adulthood. Standard 9 covers the mental health and psychological wellbeing of children and young people. It states:

All children and young people, from birth to their eighteenth birthday, who have mental health problems and disorders, have access to timely, integrated, high quality, multidisciplinary mental health services to ensure effective assessment, treatment and support, for them and their families.

The standard outlines the following vision for the future:

• An improvement in the mental health of all children and young people
• That multi-agency services, working in partnership, promote the mental health of all children and young people, provide early intervention and also meet the needs of children and young people with established or complex problems
• That all children, young people and their families have access to mental health care based upon the best available evidence and provided by staff with an appropriate range of skills and competencies

Historical background

In 1995, the NHS Health Advisory Service published a thematic review of child and adolescent mental health services (Together We Stand), which proposed a four-tier model for commissioning and delivering comprehensive services. Four years later, in the report of its audit of specialist mental health services for children and young people (Children in Mind), the Audit Commission took this four-tier approach as its baseline and confirmed its applicability to the future planning of mental health services for children.

The commission also reported substantial variations around the country in the level and mix of staff deployed in local services, in how easily services were accessed and, to some extent, in the age range of children seen; it found also significant variations in spending on services, which did not appear to be related to any established variations in need.

In recent years, the government has been striving to bring greater coherence to mental health services for children and young people and to remove the inequalities in service provision highlighted by the Audit Commission. In 1999, the Department of Health announced new investment in CAMHS and issued a circular setting out how funds were to be used.

In September 2002, Improvement, Expansion and Reform (which set out the NHS priorities for the 2003-06 planning round) set the expectation that comprehensive mental health services for children and young people would be available in all areas by 2006; it also states that CAMHS is to be increased by at least 10 per cent each year (in staffing, patient contacts and/or investment) according to local agreed priorities.

In September 2004, the Children's National Service Framework included the mental health and psychological wellbeing of children and young people as one of its 11 standards.