Children's and adolescents' mental health and CAMHS - Health Committee Contents

2  CAMHS as a whole system

25. CAMHS services have historically been conceptualised as a 4-Tier model, as follows[29]:

26. Some have argued that this model is now outdated and unhelpful, reinforcing distinctions between different of types services when an integrated service structured around the needs of children and young people would be more effective.[30] Integrated service models are discussed chapter 4.

27. This inquiry was prompted by concerns about access to Tier 4 inpatient treatment, for the most severely affected children and young people. But as with all parts of the healthcare system, Tier 4 inpatient services do not operate in isolation from other parts of the CAMHS system, but are linked to specialist outpatient services, to targeted early intervention services, and to universal services, such as support provided by schools and general practitioners. Throughout this inquiry, witnesses have emphasised the crucial role played by early intervention services in preventing mental health problems from escalating, minimising the need for inpatient care. Many suggested that this, in fact, is where the focus for investment should be. Dr Rao, a Consultant Psychiatrist from the Black Country Partnership Foundation Trust, told us:

    I do not think the solution is just tier 4 beds. If you create more beds, there will simply be more children perhaps inappropriately there. It needs perhaps a plan or a basic template for the commissioners on how to build a service, for example, with the tier 3+, with links and collaboration with tier 4.[31]

28. Michael Upsall, a commissioner from Derbyshire, put the argument in financial terms:

    For the weekly cost of a bed in a tier 4 placement, we could be talking somewhere between £5,000 and £7,000 a week—£25,000-plus a month. You can provide a lot of bespoke services in the community with a lot less funding than that … If local commissioners had easier access to that funding earlier, we could make the money go a lot further to prevent—or at the very least delay and shorten—the amount of time that a small number of young people end up in tier 4.[32]

29. Many submissions received by the Committee also linked increased demand for more specialist Tier 3 and 4 services with reductions in early intervention services, arguing that when children and young people cannot access services at an early stage, they become more unwell, and need more specialist care. One CCG which carried out a review of its services identified this as a contributory factor to increasing pressure on Tier 3 services:

    Reductions in Tiers 1 and 2 provision largely as a result of budget reductions leading to a lack of early intervention. Hence children and young people were tending to access services at too late a stage hence they required more complex and time consuming interventions to address their presenting challenges.[33]

30. Another trust stated that:

    In order to manage demand, teams may be left in a position of turning an opportunity for preventative psychologically based work away. This means a young person and their family have been turned away from early help only to return when their condition has become more challenging to work with or, distressingly, requires admission to T4 in patient services.[34]

31. The relationship between the different Tiers of care also operates in reverse-as children and young people recover from more serious periods of mental ill health, they may need ongoing care from a lower Tier service. A provider of Tier 4 services argued that when these lower Tier services are lacking, the result may be delayed discharges and repeat admissions:

    Our services have young people who wait protracted periods of time to move down the care pathway. Often, local services are fearful of the young person moving back to the community because of the extreme crisis under which they were originally referred to hospital. Local services are stretched and there is often no appropriate provision for the young people to move to. We have experienced young people waiting up to two years for an appropriate placement after they have recovered …

    … Young people can often become 'revolving door' patients. They are admitted to hospital, they recover and then on discharge, without as much support as they need, they quickly deteriorate and become a re-admission.[35]

32. One of the best illustrations of the importance of early intervention, lower tier services, and the damaging impact when such services are lacking, was given by a young person:

    If funding was increased, trained CAMHS staff could begin to tackle the problem in schools…this will greatly increase awareness of mental health in general and encourage help to be sought before crisis is reached… my lack of awareness led to my problems escalating until I was considered 'high risk' to myself and even then, I was on a waiting list. It reached a point where I was hurting myself daily to be finally be picked up by the CAMHS service. At this point I required a high level of support from services (possibly increasing expense)[36]

Conclusions and recommendations

33. Whilst most attention has so far centred on problems in accessing inpatient treatment, compelling arguments have been made to this inquiry that the focus of investment in CAMHS should be on early intervention-providing timely support to children and young people before mental health problems become entrenched and increase in severity, and preventing, wherever possible, the need for admission to inpatient services. It is clearly unacceptable if a child or young person cannot access a Tier 4 service close to their home, but for every child in this position, a further question needs also to be asked - has everything possible been done to prevent that child from becoming so unwell that they needed admission to inpatient services? The evidence we have received suggests poor provision of lower tier services may be increasing the number of children and young people requiring admission to inpatient services. This situation must be addressed by the Taskforce.

29   Source - YoungMinds Back

30   See, for example, North West London Commissioning Support Unit (CMH 0211) Executive summary; University of Reading (CMH 0135), para 7 Back

31   Q169 Back

32   Qq 235-236 Back

33   Clinical Commissioning Groups within Staffordshire and Staffordshire County Council (CMH0134) para 2.3  Back

34   Central and North West London NHS Foundation Trust (CMH0132) para 2 Back

35   Alpha Hospitals Ltd (CMH0068) para 2 viii, x Back

36   GIFT Partnership (CMH0159), para 3 Back

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Prepared 5 November 2014