Select Committee on Health Minutes of Evidence


Memorandum by Young Minds

RELATIONSHIP BETWEEN HEALTH AND SOCIAL SERVICES (HSS83)

SUMMARY OF RECOMMENDATIONS

1.  AGENCY RESPONSIBILITIES

  clarity of responsibility for a comprehensive CAMHS across and within agencies needs to be achieved

  primary care group commissioning must take full account of the scope of CAMHS and must clarify commissioning boundaries with Health Authorities

  specialist adolescent mental health services should be developed with an age range of 13-25 and should remain within the children's health and social service areas

  a mandatory arrangement, such as the care programme approach, should be instituted so that adolescent service workers must meet formally with adult service workers and agree a care plan that will be followed by the latter, before the former can relinquish responsibility for the young person

  the young person concerned should have a right to demand the service identified in the care plan in the same way that a community care assessment confers certain rights.

2.   ORGANISATIONAL STRUCTURES

  CAMHS should be firmly placed within Children's Services—both in Health and Social Services, even though it means that services for young people up to the age of 25 are provided. (This is not difficult for Social Services who have the legal ability to provide beyond the age of 18 where it is appropriate to do so—although there are some fairly draconian cut-off decisions for resource reasons.)

  The planning of CAMHS should be grounded in the Children's Services Planning (CPS) process. Thought needs to be given to the bringing together of the various local authority planning processes that effect children and the way in which Health Authority's commissioning intentions are reflected. Possibly the CSP could have an over-arching responsibility for the other processes if not completely absorbing them.

  CAMHS professionals must have a place in the planning and contracting process, as well as in the discussion with commissioners on the "vision" for the service.

  One agency is given the overall responsibility to lead on comprehensive CAMHS and will be expected to liaise across all these boundaries with particular responsibility to work with tier one professionals. (Time to do this must be clearly commissioned.) This would require staff to be seconded across to the lead agency or to be employed directly by the lead agency eg social workers and EPs by Health or EPs and child psychiatrist by Social Services. (Professional support to these groups can be arranged as necessary outside the lead agency.) This structure requires a rigorous monitoring system which ensures that the lead agency is complying with the agreed service "vision".

3.   INCENTIVES FOR JOINT WORKING

  All of the MISG should be considered for spend on CAMHS.

  Joint finance should be increased with the specific aim of creating joint CAMHS teams across health, social services and education.

  Staff should be encouraged to see themselves as able to use their skills in multi-professional teams and to see this as the future eg the development of "boundroids".

4.   ORGANISATIONAL AND FUNDING SYSTEMS AND PROCESSES FOR PLANNING, COMMISSIONING AND SERVICE DELIVERY

  Service planning processes be brought together within the CSP with planning for CAMHS having a clear place.

  CAMHS "teams" should be brought together via direct employment or secondments if necessary and be under one roof.

  Some direct access to specialist services should be preserved.

5.   TRAINING AND PROFESSIONAL BOUNDARIES

  Training in child development, to promote the understanding and assessment of risk and protective factors in relation to mental health, is essential for people working with children and young people in all settings.

  The skill mix in CAMHS teams needs to be flexible to meet the needs at any given time.

  The "best" worker for the client should be allocated, irrespective of that person's particular professional background.

 6.  RELATIVE COST-EFFECTIVENESS OF SERVICES AND THE MOVEMENT OF MONEY BETWEEN SECTORS

  Money must be redirected to mental health promotion, early identification of problems and early, appropriate intervention. This will need to be done across the public sector agencies, not only within them.

  Sufficient specialist resources, for young people, must be made available in every health district. PCG commissioning must address this.

  Use of resources between agencies needs to be freed up, within joint agreements, to be more flexible and responsive to local need.

7.  RECRUITMENT/RETENTION OF STAFF

  Commissioners must ensure that contracts encapsulate the "vision" for a comprehensive CAMHS and that the funding of each element of the service is clearly set out.

  Staff must have an expectation that day-to-day supervision will be provided within the team and that their professional development will be provided for.

  Where staff are seconded into or directly employed by a lead agency which is not their "parent" agency the employment conditions must be secure and clear.

8.  BARRIERS AND INCENTIVES TO ENCOURAGE OR DISCOURAGE THE USE OF PARTICULAR SERVICES

  Information-giving and education about child and adolescent emotional well-being needs to be given some priority within the CSP, within PHSE and in parent education wherever that is happening.

  Agencies need to be aware of the stigma which attach to them and to ensure that these do not inhibit referral and/or information-giving.

  Agencies need to explore their use of language to ensure that services are properly targeted.

MEMORANDUM

    (i)  Information about YoungMinds is appended at A.

    (ii)  This submission will confine itself to services for the mental health of children and young people. It will be based on a broad definition of mental health as proposed in the Health Advisory Service (HAS) thematic review "Together we Stand". This emphasises the importance of health and emotional well-being and understands the importance of nurturing children's development to enable them to become well-functioning people of the future. With this in mind this submission will address issues of mental health promotion and the prevention of mental health problems in childhood, as well as of treatment.

    (iii)  It will focus on the importance of the collaboration of a wide range of agencies that have bearing on the development of children and their families. It will describe service provison at different levels using the framework of the tiered structure for a comprehensive child and adolescent mental health service (CAMHS) as set out in "Together we Stand". In this framework services include support and guidance offered informally, eg by family members, relatives and front line professionals such as GPs, social workers, teachers right through to the very specialist services, eg child and family consultation services (CFCS) in-patient units. The tiered framework is set out diagrammatically at appendix B.

    (iv)  The areas of enquiry suggested in the Terms of Reference are followed.

1.  AGENCY RESPONSIBILITIES

  1.1  The concept of a comprehensive child and adolescent mental health service is that it includes a wide range of agencies concerned with the emotional development and welfare of children.

  1.2  Services for the mental health of children and young people are arguably the most complicated to organise as they are provided by a range of professionals who are employed across a range of agencies or, in the case of GPs and providers of highly specialised care, are independent contractors.

  1.3  Similarly a variety of purchasing arrangements adds to the complexity, eg Health authorities (HAs), Local Authorities (LAs) which include Social Services Departments (SSDs) and Education Authorities (EAs), Local Management of Schools (LMS) and GP Fund holding (GPFH). Soon to come are Youth Offender Teams (YOTs) and Primary Care Commissioning Groups (PCCGs). There is enormous scope for what can only be described as buck-passing and cost-shunting.

  1.4  Within agencies responsibilities for children's mental health are often unclear, with the confusions occurring between frontline and specialist services and between childrens and adult services. The latter is a particularly important issue for adolescents and young adults who, at an extremely vulnerable period of their lives, are shunted between children's services, in both health and social services, and adult mental health services, where there is scant recognition of their particular needs and the importance of liaising closely on a specific care plan with the children's services.

  1.5  Recommendations

  Clarity of responsibility for a comprehensive CAMHS across and within agencies needs to be achieved

  Primary care group commissioning must take full account of the scope of CAMHS and must clarify commissioning boundaries with Health Authorities

  Specialist adolescent mental health services should be developed with an age range of 13-25 and should remain within the children's health and social service areas

  A mandatory arrangement, such as the care programme approach, should be instituted so that adolescent service workers must meet formally with adult service workers and agree a care plan that will be followed by the latter, before the former can relinquish responsibility for the young person

  The young person concerned should have a right to demand the service identified in the care plan in the same way that a community care assessment confers certain rights.

2.  ORGANISATIONAL STRUCTURES

  2.1  The organisations which together deliver a child and adolescent mental health service are as follows:

    —  Schools—Special Educational Needs Coordinators (SENCOs) taking a specific responsibility

    —  Education Authorities—providing Educational Psychologists (EPs) and Education Welfare Officers (EWOs) and the monitoring of Behaviour support plans (BSPs), contribution to the Children's Services Plan (CSP), managing education otherwise than in school and managing the Early Years Service, including the requirement to produce a report on these under Section 19 of the Children Act.

    —  Voluntary organisations which provide a range of counselling services of varying quality and intensity, grant aided by both LAs and HAs

    —  The Youth Service—often providing counselling but equally importantly providing opportunities for physical exercise

    —  Social Services Children's services and youth justice services, supporting children and families in need and young people caught up in the justice system, as well as offering some therapeutic support for young people who have suffered abuse, including neglect—both physical and emotional—largely via its contributon to CFCS and taking responsibility for Children's Services Planning

    —  Social Services adult mental health services, which cater for young people over 16 and, in many cases, for much younger children who are seriously ill and which reflect this in the Community Care Plan

    —  Probation Service via its support to over 16's in the justice system

    —  Health Services, providing tier one support via GPs, community child health services—particularly school nurses and health visitors and specialist CAMHS usually via the CFCS staff which include child psychiatrists, family therapists, child psycholtherapists, CPNs, paediatric OTs as well as liaison work with acute paediatrics and specialists services eg for children with learning disabilities, children with chronic ill health

  2.2  The contribution made by the health services is complicated as there is no one clear lead department for specialist CAMHS. Some specialist CAMHS are in Child Health and some are linked to Adult Mental Health Departments. In both cases it is usually split off, in line management terms, from the tier one services with which it must work ie school nurses and health visitors and from the tier two services of the CPNs. Different areas configure their services in different ways and there needs to be some clarity, primarily to ensure that CAMHS is planned properly—as a service in its own right and by people who are involved in its delivery. Too often CAMHS seem to be part of a wider planning process which allows no direct input from the speciality.

  2.3  Recommendations

  CAMHS should be firmly placed within Children's Services—both in Health and Social Services, even though it means that services for young people up the othe age of 25 are provided. (This is not difficult for Social Services who have the legal ability to provide beyond the age of 18 where it is appropriate to do so—although there are some fairly draconian cut-off decisions for resource reasons.)

  The planning of CAMHS should be grounded in the Children's Services Planning (CSP) process. Thought needs to be given to the bringing together of the various local authority planning processes that effect children and the way in which the Health Authority's commissioning intentions are reflected. Possibly the CSP could have an over-arching responsibility for the other processes if not completely absorbing them.

  CAMHS professionals must have a place in the planning and contracting process, as well as in the discussion with commissioners on the "vision" for the service.

  One agency is given the overall responsibility to lead on comprehensive CAMHS and will be expected to liaise across all these boundaries with particular responsibility to work with tier one professionals. (Time to do this must be clearly commissioned.) This would require staff to be seconded across to the lead agency or to be employed directly by the lead agency eg social works and EPs by Health or EPs and child psychiatrist by Social Services. (Professional support to these groups can be arranged as necessary outside the lead agency.) This structure requires a rigorous monitoring system which ensures that the lead agency is complying with the agreed service "vision".

3.  INCENTIVES FOR JOINT WORKING

  3.1  The recent extension of the mental illness specific grant is welcome. YoungMinds hopes the money which is specifically targeted to CAMHS will be distributed imaginatively to seed joint projects which will have an impact on the overall CAMHs structure in the particular locality. The use of other MISG monies to focus on joint working in CAMHS would clearly be useful eg joint examination of the expenditure on ECRs and private placements of challenging children.

  3.2  Joint Finance could also be used more imaginatively to fund specific joint developments indicated by the CAMHS planning process, with an emphasis on the setting up of joint teams under a single line management within a management structure which satisfies the governance arrangements of the agencies involved eg this may mean that a HA non-executive board member and a local authority councillor should be members, as well as PCCG representatives.

  3.3  Staff seconded into or employed by the lead agency which they may not see as their professional "home" need to have their employment rights safeguarded. Staff worry about joint teams and leaving the parent organisation largely for reasons of financial and professional security. These issues cannot be ignored.

  3.4  Recommendations

  All of the MISG should be considered for spend on CAMHS.

  Joint finance should be increased with the specific aim of creating joint CAMHS teams across health, social services and education.

  Staff should be encouraged to see themselves as able to use their skills in multi-professional teams and to see this as the future eg the development of "boundroids".

4.  ORGANISATIONAL AND FUNDING SYSTEMS AND PROCESSES FOR PLANNING, COMMISSIONING AND SERVICE DELIVERY:

  4.1  All agencies need to come together—possibly within the CSP process—to identify what they are spending on services to children with mental health problems and to consider pooling their resources on the basis of a shared vision/plan. On this same basis they need to identify areas for development and to work out how resources should and can be shifted as necessary. This process may also include bidding for further funds which, given the tiny proportion of public funds actually allocated to CAMHS cannot be sidestepped.

  4.2  Pooled funding can be problematic at present as legislation is proscriptive about use of public funds. However with proper accounting methods this need not be an insurmountable problem.

  4.3  The possibility of identifying a lead agency has been touched on above. The commissioning of CAMHS must include sufficient capacity to manage the services effectively. At present most specialist CAMHS have very long waiting lists which mean that many young people can be assessed as needing specialist support but that it is not forthcoming within a helpful time scale. As a result there are suicides that might have been prevented etc. Commissioners need to plan with providers a way of dealing with this, eg a temporary task force—and to ensure that resources in the base budget are redirected so that there is enough child psychiatrist time to support and supervise teachers, school nurses, social workers, GPs etc. at the very early stages of the onset of problems, in order to reduce the number young people needing the very specialist, and costly, services.

  4.4  Service delivery will be aided—on balance—by accommodating the "team" together and by having a reasonable number of access points. Direct access to specialist CAMHS is appreciated by some people and indeed some people will not get the support they need unless all barriers are removed. For example some young people do not want to talk to their GP about their feelings and some families cannot always find the right routes into services eg travelling families, refugee families.

  4.5  Recommendations

  Service planning processes be brought together within the CSP with planning for CAMHS having a clear place.

  CAMHS "teams" should be brought together via direct employment or secondments if necessary and be under one roof.

  Some direct access to specialist services should be preserved.

 5.  TRAINING AND PROFESSIONAL BOUNDARIES

  5.1  It will continue to be important to train a range of professionals in their specific skills. As people move into multi-skill teams they need to be grounded in their particular professional competancies in order to be clear about the type and level of intervention they are able to make before calling on other team members' assistance. In addition, all professional trainings need to include an agreed basic training in child development and an introduction to the values and competancies of other professionals. They need to understand risk and protective factors and to know what local services and facilities are available to build the protective factors.

  5.2  Multi-professional, multi-skill specialist CAMHS teams need to be able to vary the professional mix as indicated by the referrals to their services. Allocation of cases should be made according to the expertise, allowing those with the best understanding of the client/patient/service user to hold the case and to bring in other skills as necessary. It should not be necessary for every case to be assessed by the child psychiatrist. GP fund holding has made this the norm, for financial reasons, and it is wasteful of the team resources in many cases.

  5.3  As primary care commissioning takes hold it is important to ensure that multi-professional, multi-agency teams are seen as a whole and not dissected into what health can buy and what social services can buy. The involvement of social services in the PCCGs should be able to deal with this. (This point is developed in Section 6.)

  5.4  Where teams do not develop under a single management with a single "vision", training is essential to heighten awareness of frontline staff to children's mental health issues. This is best done by bringing people together across the agencies to train together. YoungMinds' early experience in offering training in this way has produced very positive feedback.

  5.5  Recommendations

    —  Training in child development, to promote the understanding and assessment of risk and protective factors in relation to mental health, is essential for people working with children and young people in all settings.

    —  The skill mix in CAMHS teams needs to be flexible to meet the needs at any given time.

    —  The "best" worker for the client should be allocated, irrespective of that person's particular professional background.

    —  Primary Care Group commissioning should seek to use CAMHS teams efficiently across the skill mix and not attract particular professional responses for financial reasons.

6.  RELATIVE COST-EFFECTIVENESS OF SERVICES AND THE MOVEMENT OF MONEY BETWEEN SECTORS

  6.1  There is now compelling research evidence, both in Europe and the USA, to indicate that early identification of mental health problems, and early and appropriate intervention, prevents destructive and self destructive behaviour in later childhood and adolescence as well as reducing the chances of mental illness in adult life. The cost of dealing with these behavious and of managing mental illness are considerable and therefore it is clearly cost-effective to target resources on early identification/intervention.

  6.2  Positive promotion of mental wellbeing, achieved through parenting education and intensive support to vulnerable families at particularly vulnerable points in their life cycle eg, becoming a parent, managing a teenager, is equally important. "Our Healthier Nation" recognises this.

  6.3  There are perverse incentives operating which make the financial shifts difficult, in that the Health Services, which will have to find the largest amount of money to redirect, are not the main beneficiaries in the longer term. The local authorities and the justice services are more likely to feel the impact of earlier intervention. (ref research by Prof. M. Knapp LSE).

  6.4  In terms of service delivery, YoungMinds receives a great deal of information—through the Parent Information Service—about the shortcomings of the specialist CAMHS. This is largely about accessibility ie, availability of a service at the time it is needed. This suggests to us that CAMHS are severely stretched in providing for those who are referred to them.

  6.5  We also know that many young people are not referred because access to treatment is so poor, and many who cannot get immediate attention have to be passed on to institutional services which are not indicated and which are often a long way from home. This in itself can be very damaging to a young person. In extreme situations young people are placed in adult psychiatric beds which they find very distressing and which is entirely inappropriate. The current work of the Audit Commission should clarify the national picture.

  6.6  Currently legislation does inhibit the most creative and effective use of health and local authority resources at the interface because of the constraints on the expenditures of both. Ideally there needs to be some permissive legislation which allows for a percentage of each agency's finance to be spent on the activities of the other where certain joint arrangements are in place, eg criteria similar to that proposed for the Special Transitional Grant (STG) new arrangements in relation to community care services. For example a jointly commissioned CAMHS team might want to replace a social work post, funded from the base budget, with a CPN because of the nature of its referrals and/or follow up work. This needs to be possible, and it is to be hoped that the Social Services white paper will provide for this.

  6.7  Recommendations

  Money must be redirected to mental health promotion, early identification of problems and early, appropriate intervention. This will need to be done across the public sector agencies, not only within them.

  Sufficient specialist resources, for young people, must be made available in every health district. PCG commissioning must address this.

  Use of resources between agencies needs to be freed up, within joint agreements, to be more flexible and responsive to local need.

7.  RECRUITMENT/RETENTION OF STAFF

  7.1  The best way to retain staff is to ensure that the service is effective, forward-looking and creative, offering them ample opportunity to contribute to its development. This is difficult in CAMHS which are often provided in an uncoordinated way across a number of agencies, with tenuous links between them. The existence of an inter-agency "vision" and a clear and comprehensive contract with the commissioners are prerequisites.

  7.2  The development of a joint HA and LA service can inspire and energise staff who are able to learn from and appreciate the skills of others whilst feeling more confident that their services are not overlapping in some places and non-existent in others.

  7.3  Opportunities should exist for further training and professional development and it should be an expectation that all staff will take full advantage of these. Most importantly there needs to be on-going training in cross-agency roles and working to ensure that rivalries and buck-passing do not develop. Regular supervision from a line manager on day to day work is both essential for staff retention and development as well as ensuring that quality is maintained.

  7.4  Seconding staff into another agency or employing them directly must be accompanied by clear employment rights protection. The opportunity for off-line professional consultation if and when needed must be negotiated. Where staff are seconded into a joint team it is not helpful to have them on rotation. The disruption to the staff group which this causes does not allow the team to build or for the continuity of the client/patient/service user relationship. There are already difficulties in CAMHS teams in managing doctors on rotation, exacerbated by the small size of most CAMHS teams.

  7.5  Recommendations

  Commissioners must ensure that contracts encapsulate the "vision" for a comprehensive CAMHS and that the funding of each element of the service is clearly set out.

  Staff must have an expectation that day-to-day supervision will be provided within the team and that their professional development will be provided for.

  Where staff are seconded into or directly employed by a lead agency which is not their "parent" agency the employment conditions must be secure and clear.

8.  BARRIERS AND INCENTIVES TO ENCOURAGE OR DISCOURAGE THE USE OF PARTICULAR SERVICES

  8.1  It is crucial that the emotional well-being of children and families is safeguarded for the reasons set out above. It is therefore essential that people know about the supports which exist in their communities and that they also have an appreciation of mental health issues. This requires a communication strategy.

  8.2  The CSP has a role in letting people know about services but needs to be more widely available. People have spoken to us about the helpfulness of classes offered by schools on particular aspects of parenting. Adolescence is a difficult time for parents who may have very little understanding of what the young person is experiencing. Schools can respond to this, both in offering parent education and through personal, health and social education (PHSE) within the school.

  8.3  Research shows us that people do not want to come to Social Services Department with their anxieties for a range of reasons. As social services resources shift towards family support this may change. At the moment universal settings such as schools and early years provision should be encouraged to take the lead in providing information and to actively undertake mental health promotion with families.

  8.4  The language used to describe children and young people with mental health problems is different in each agency. The Education service is concerned with the school refuser and the young person with behaviour problems or conduct disorders. Social Services are concerned with the child who has been emotionally neglected and who is at risk. Probation services are concerned with the young offender. General health services are concerned about early pregnancy and poor attachment. Specialist CAMHS are concerned with problems and disorders.

  8.5  There needs to be some mutual understanding that these terminologies all describe a lack of mental well-being which is likely to have its roots in very similar sets of circumstances. The different terminologies are unlikely to describe differing levels of severity and a discussion may be very helpful in targeting resources more appropriately.

  8.6  Recommendations

  Information-giving and education about child and adolescent emotional well-being needs to be given some priority with the CSP, within PHSE and in parent education wherever that is happening.

  Agencies need to be aware of the stigma which attach to them and to ensure that these do not inhibit referral and/or information-giving.

  Agencies need to explore their use of language to ensure that services are properly targeted.


 
previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries

© Parliamentary copyright 1998
Prepared 10 August 1998