Select Committee on Health Fourth Report



166. Our main concern in this inquiry has been to consider how patients move around the system: whether transitions are managed smoothly; whether there is capacity where it is needed; and whether there are any perverse incentives preventing patients from being in the most appropriate place. We were aware from our previous inquiries into child and adolescent mental health services[385] and looked-after children[386] that services were far from adequate, and we were therefore particularly anxious to investigate in this inquiry how well these often patchy services fitted into the larger picture of adult services.

167. The evidence with which we were presented was far from reassuring. The first point made to us by a range of witnesses was the complete lack of consistency as regards the age at which young people transfer from child and adolescent mental health services [CAMHS] to adult services.[387] Young Minds, for example told us that "cut-off" points for children varied between 16 and 19, and often depended on whether children were in full-time education; services for those aged 16 and 17 and not in full-time education were often arranged on an ad hoc basis or were non-existent.[388] The Sainsbury Centre for Mental Health told us similarly that many 17 and 18 year olds fall through the gap.[389] Dr. Surya Bhate of Newcastle City Health NHS Trust, demonstrated the wide range of ages used to determine "adolescence", telling us that his adolescent forensic service theoretically served young people up to the age of 21, and in practice up to the age of 22.[390]

168. The fact that the age of transfer varies from area to area, or patient to patient, might not be a matter for concern if it was clear that there were good links between CAMHS and adult services, that patients were transferred when appropriate, and that they continued to receive the services they needed. Unfortunately, clear systems that link CAMHS and adult services would appear to be the exception rather than the rule. The Centre for Mental Health Services Development at King's College London, for example, referred to the "widespread and notorious" lack of communication between adolescent and adult mental health services[391] and Antek Lejk of Local Health Partnerships NHS Trust told us that in his trust such transitions were not based on clear protocols, but rather "on conversations between the people who may or may not choose to co-operate", with consequent "hit and miss" results.[392] The Children's Society presented us with a range of case-studies demonstrating how adolescents could be left stranded without the support they needed and had been getting from adolescent services, and argued for a more phased transition to adult services.[393] The Eating Disorders Association highlighted the particular problem of the transition from highly specialised eating disorder services to general adult mental health services, where the professionals involved in delivering care may have little or no specialist knowledge of eating disorders. The EDA argued that such problems are exacerbated by poor communication between professionals and a lack of support for the young adult in the transitional phase.[394]

169. One of the reasons for this poor communication is clearly the result of the very different cultures that operate within CAMHS and adult services. Young Minds contrasted the "family systems" approach of CAMHS, who would be willing to work on issues like family relationships or work problems, with the more "medical model" of adult services, which tend to focus more on diagnosis and treatment of the individual.[395] The British Psychological Society similarly emphasised the "cultural differences" between the two services,[396] while Professor Finlay Graham of Newcastle City Health NHS Trust was more forthright, telling us:

    "I think children and adolescent services are running on entirely different principles. Inevitably that will have a negative impact on the transfer."[397]

170. Witnesses also emphasised to us how "adult" mental health conditions such as schizophrenia and other mental illnesses often emerge in late adolescence. It is therefore crucial both that these conditions are recognised and that patients who have been diagnosed and treated do not slip out of the system when they reach the age of 16 or 18. The National Schizophrenia Fellowship argued that there is little support for teenagers experiencing the onset of such adult mental illnesses.[398] The Royal College of Psychiatrists similarly commented that many "adult disorders" arise in childhood, but that services are too busy "fire-fighting" other demands to deal with them appropriately.[399] This theme of the general inadequacy of child and adolescent services was certainly taken up by many of our witnesses,[400] with Young Minds commenting that it is a "misnomer" even to speak of "adolescent" services as services geared specifically at this age-group are so rare.[401] Both the National Schizophrenia Fellowship[402] and the South London and Maudsley NHS Trust[403] drew our attention to the value of "early intervention" projects for first onset psychosis, such as the "IRIS" project which we saw on our visit to Northern Birmingham Mental Health NHS Trust. Although these early intervention schemes aim to provide care for anyone suffering from a first episode of psychosis, many such individuals will be teenagers. The South London and Maudsley NHS Trust told us that there is a "critical period" early on in the course of the illness, where cognitive therapy and family interventions as well as drug treatment will help reduce the probability of relapse.

171. A range of solutions and improvements were suggested to us by our witnesses. The obvious conclusion to draw from the problem of the "no-man's land" into which many 16-18 year-olds seem to disappear, would be to set a standard age at which adolescents should pass from CAMHS to adult services. The Centre for Mental Health Services Development at King's College London, for example, argued for standardised age-bands.[404] Department of Health officials expressed some concern over the idea of a fixed age, arguing that chronological age might be a very poor indicator of a young person's needs.[405] Finlay Graham of Newcastle City Health NHS Trust suggested that it would be helpful to have a "target age" of 18, 19 or 20, but with the proviso that it need not be observed rigidly.[406] While we appreciate the Department's point that adolescents mature at very different speeds, we do feel that the current system offers the worst of both worlds: the evidence we cited above suggests that the lack of a national agreed target age for transfer is not on the whole used to enhance local flexibility, but simply creates a patchwork of incompatible services. We find it quite extraordinary that in certain parts of the country 16 and 17 year olds who are not in education can be excluded from both child and adult services, at a time when they may be most vulnerable. We recommend that the Department should consult on the most appropriate age, on average, for transfer to adult services and set that age as a national target age for transfer. Local services would then be clear what the normal age for transfer was, but would be able to vary this as appropriate for individual patients. We also recommend that, whatever the age chosen, there should be no possible gap between adolescent and adult services.

172. It is clear from the evidence we have received that the question of the age at which adolescents transfer is not the only hindrance to smooth transitions between CAMHS and adult services. We discussed above (see paragraph 169) the cultural differences between the services and the regular lack of communication. The Sainsbury Centre for Mental Health Services emphasised the need to establish clear mechanisms for transfer, such as the creation of "care pathways" and the designation of one practitioner to act as a care manager across a range of services.[407] The NHS Confederation highlighted the differences between the Health Advisory Service four tier framework of services which is used for child and adolescent mental health services, and the National Service Framework,[408] and a number of witnesses argued that there

should be a National Service Framework for children.[409]

173. We believe that the current poor relationships between child and adolescent mental health services are highly unsatisfactory. We are aware that the National Service Framework, although aimed primarily at adults, does touch on interface issues between adolescent and adult services. We recommend that the Department should require local NSF Implementation Groups specifically to consider how working relationships between these two services could be improved, and should ensure that the monitoring of the NSF pays particular attention to this issue.

174. The most radical solution to the problem of poor transitions between CAMHS and adult services which was put to us was the creation of a "youth service" to cater for young people between, for example, 16 and 25.[410] We felt that this proposal was attractive in many ways: it would avoid the need for transfer at a time when adolescents are particularly vulnerable and could encourage the development of specialist services identifying the onset of psychosis in late teens.[411] At the same time, as the Mental Health Foundation pointed out to us, such a service would bring its own service boundary issues to be resolved.[412] Martin Ward of the Royal College of Nursing suggested that the choice of 16-25 "seems to be chronologically an arbitrary decision" and argued that "I would not, as a twenty-four year old, want to be put into a youth service".[413] Mr. Ward went on to give an examples from Birmingham and Edinburgh which he felt would work better than a catch-all 16-25 service:

    "From 14 to 19 they are offered the option of going into a youth service and then at 19 they go into an adult service. It is about this notion of giving individuals who are going to use these services the option as to where they are placed, which is probably more fundamental than the service itself."[414]

175. We agree that one of the most important factors for young people in the services provided for them will be a factor of choice. We also appreciate that a service aimed at young people, whether 14-19, 16-25, or any ages in between, will have its own boundary issues to resolve. We do, however, feel that it is an idea worth pursuing. We recommend that the Government should commission research on how such services are working in this country and elsewhere, with a firm commitment to developing them if good models emerge.

385   Child and adolescent mental health services, Fourth Report of the Health Committee (HC 26, Session 1996-1997). Back

386   Children looked after by local authorities, Second Report of the Health Committee (HC 319, Session 1997-1998). Back

387   eg Ev., p70; Ev., p295; Ev., p306; Q149. Back

388   Ev., p70. Back

389   Ev., p297. Back

390   Q376. Back

391   Ev., p295. Back

392   Q440. Back

393   Ev., pp328-329. Back

394   Ev., p262. Back

395   Ev., p70. Back

396   Ev., p150. Back

397   Q381. Back

398   Ev., p63. Back

399   Ev., p152. Back

400   eg Ev., p274; Ev., p295; Ev., pp306-307;Ev., p323. Back

401   Ev., p70. Back

402   Ev., p64. Back

403   Ev., p323. Back

404   Ev., p295. Back

405   Q52. Back

406   Q376. Back

407   Ev., p297. Back

408   Ev., p287. Back

409   eg Ev., p146; Q149. Back

410   eg Ev., p70; Ev., p152. Back

411   eg Ev., p63; Q532. Back

412   Ev., p274. Back

413   Q532. Back

414   Q532. Back

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