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.
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