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

3  Early intervention mental health services (Tier 2)

34. Early intervention mental health services at Tier 2 can be delivered by CAMHS, voluntary sector providers or other agencies. These provide mental and emotional health services for children and young people who require support, but who do not require more highly specialised Tier 3 services.

35. Liverpool CAMHS Partnership have adopted a comprehensive pathway approach for their CAMHS service, with a focus on early intervention and prevention; they report that this approach has helped them achieve reduction in specialist CAMHS (Tier 3) referrals in 2011/12 and 2012/13 and Tier 4 (although there has been a slight rise this year).[37] Several areas described Primary Mental Health Worker services providing early intervention, including Tees, Esk and Wear Valleys NHS Foundation Trust:

    Via Primary Mental Health Workers (PMHWs) we have embedded links in education, training programs in our partner agencies, open access and consultation and liaison. All our clinical pathways include early detection and early intervention. We now have a Social and Emotional Wellbeing pathway which covers short term interventions and where indicated entry into other diagnostic pathways. Notably we are integrating our crisis work with our early intervention/prevention services.[38]

36. However, many organisations submitting written evidence gave examples of early intervention services in their areas that had been cut or reduced:

    Birmingham has traditionally had a strong ethos of early intervention and prevention work, much of this has been developed on a multiagency basis through initiatives such as the Children's Fund, Birmingham Brighter Futures, Sure Start, TAMHs and more recently the Big Lottery. The focus of this work has been on improving parenting skills and developing emotional resilience in children. These traditions have been difficult to maintain for CAMHS over the last three years … In particular the reductions in funding have significant impact on the Primary Mental Health Worker Service where there have been reductions in staff. There has also been a reduction in the number of children under 5 who are seen by CAMHS in contrast with provision ten years ago when there was a strong emphasis on pre-school work and early intervention resulting from reductions in ABG funding. The shift in emphasis to severe and complex work can result in the late offer of CAMHS being too little too late. [39]

37. Derbyshire Healthcare NHS Foundation Trust argue that in their locality, there has been a direct link between the loss of their Primary Mental Health worker scheme and a recent increase in referrals to Tier 3 services.[40] Solihull report that funding cuts have resulted in disbanding of an infant mental health service and discontinuation of early intervention service to 0-8yr olds who have witnessed domestic violence.

    These changes have been pushed through despite an overwhelming body of evidence to support intervening early in a child's life to minimise risks to both physical and mental health and its impact on the child's ability to achieve his/her potential and become productive individuals.[41]

38. Berkshire Healthcare NHS Trust reports that it has been informed by all but one of the six local authorities that provide Tier 2 services that there will be a reduction either in funding or in the services they offer:

    At the most extreme this has involved the loss of a gold standard 'tier 2 hub' providing integrated primary mental health workers, psychologists, therapists and family intervention workers with a jointly funded social care/CAMHS worker. This has not been replaced and tier 2 services in that area are now limited to counselling, services, a small parenting team and the behavioural support provided by schools.[42]

39. In oral evidence Jane Lunt of Liverpool CCG described voluntary sector services as "absolutely integral" to the success of their approach: "without their input and their flexibility in the way they can work with families and children, we would not be in the place we are in."[43] At our session with young people, we also heard from many voluntary sector early intervention providers. They described extremely fragile funding arrangements and increasing uncertainty about their future sustainability. London and South East CYP-IAPT Learning Collaborative provided a stark example from its patch:

    One Voluntary Sector organization within the Collaborative is facing potential Local Authority disinvestment this year that amounts to 44% of its annual income. Given a number of staff are voluntary, the overheads for the service are small, and its approach to care unique in the local area. It may not retain its CYP IAPT trained CBT therapist. [44]

Commissioning early intervention and voluntary sector services (Tier 2)

40. The evidence we have received in the course of this inquiry has been unanimous in emphasising the importance of early intervention services, many of which are delivered by voluntary sector providers. The Chief Medical Officer's report gives the example of the cost savings associated with parenting programmes as an early intervention:

    NICE guidance recommends the use of evidence-based parenting programmes as a secondary prevention measure for parents of children who have been identified as at high risk of developing oppositional defiant disorder or conduct disorders, or who already have these disorders. Costs of group parenting programme delivery have been estimated to range between £670 and £4,100.97, Bonin et al. modelled the likely long-term savings to society of implementing an evidence-based parenting programme for the prevention of persistent conduct disorders, estimating that this could result in savings of about £17,500 per family (2012 prices) over 25 years (compared with a cost of £1,016-£2,218).[45]

41. Early intervention services can be commissioned and funded by a variety of different bodies-mainly local authorities, but in some instances by individual schools or by CCGs. The role of schools and services provided within schools is discussed in the next chapter.

42. While the importance of such services has been repeatedly emphasised, the Committee has heard many reports of early intervention services being an 'easy target' for cuts during these current times of financial constraint within local authorities. Youth Access provides the following information about cuts in funding experienced by its membership of voluntary sector organisations:

    Since 2010, most YIACS have reported reduced funding. In 2010, 86% of providers reported reductions, although only 22% said this in 2013. YIACS have always been vulnerable, largely because they sit between a wider system of young people's services and statutory mental health. A lack of ownership and ambivalence, despite often representing the most significant resource alongside CAMHS in meeting mental health needs, has allowed YIACS to be easy targets for cuts. Over the years, individual services have set up and closed, including some closures over the past four years. With national policy stressing the importance of mental health and better early intervention and prevention, these cuts make no sense at all.[46]

43. Data obtained and published by YoungMinds suggests that 60% of local authorities responding have either cut or frozen their CAMHS budgets since 2010-2011, and 55% of local authorities that supplied data have cut, frozen, or increased their CAMHS budgets below inflation between 2013-14 and 2014-15.[47]

44. Local authorities and clinical commissioning groups (CCGs), as members of Health and Wellbeing Boards, jointly prepare Joint Strategic Needs Assessments (JSNAs) for their local area; these are supported by Joint Health and Wellbeing Strategies (JHWS), which are strategies for meeting the needs identified in JSNAs.[48] In December 2013 the Children and Young People's Mental Health Coalition conducted a review of Joint Strategic Needs Assessments (JSNAs) and Joint Health and Wellbeing Strategies (JHWS) and found that two thirds of JSNA did not measure children and young people's mental health, and one third of JHWSs did not prioritise children and young people's mental health. They argue that "this is of grave concern as these documents influence local commissioning strategies."[49]

45. Commissioners giving evidence to the inquiry described the difficulties faced by commissioners in prioritising CAMHS early intervention services:

    I think it is about sustainability of funding at a time when the organisations contributing to the pot are having to focus on core business, and it is sometimes difficult to argue that that is core business. You are not inspected on that. You don't fail inspections on that, and that is the harsh reality certainly for local authorities and for health services as well.[50]

46. One witness argued that the biggest challenge to running integrated services was not funding, but in achieving proper ownership across agencies. He described an autism service in his area, which at one point was declared a beacon site, now struggling because it is "nobody's child".[51] North West London Commissioning Support Unit described fragmentation of funding for early intervention work, and the problems this causes:

    …Funding for mental health prevention or emotional well-being is now fragmented between Public Health, Schools and Academies and Education. Links between national and local prevention initiatives are unclear as are relationships between, prevention campaigns and local CAMHS.[52]

47. The Committee did hear evidence that in some areas integrated working was working well, and that Local Authority directors of Public Health and Health and Wellbeing Boards were positive developments:

    ….Our JSNA does have children's information in it. It has CAMHS information in it. We have Councillor Robathan in Westminster council, a talented, passionate local politician, who tasked me to do a task and finish group on CAMHS and report to her in September. She came to the launch. With people like that in local authorities, health and wellbeing boards are in good hands. Maybe we are fortunate, but that kind of process has made quite a difference. She was very involved, and she expects a report back in a month's time; I shall be talking to her about this. It works. It is an enormous agenda; maybe we are fortunate.

    …..Most of the funding of the third sector that was in health was in Public Health, so that has now moved into the local authority. It is ring­fenced in Public Health and they would be part of driving JSNAs and making sure information is better. Public Health is a real asset for local authorities to exploit, I think. But local authorities, of course, as I mentioned before, are subject to austerity, and the very same money you might want to use to grow your third sector—voluntary organisations—will be under scrutiny in terms of reductions.[53]

48. However Central and North West London NHS Foundation Trust argued that recently reorganised Public Health Services are "only partially engaged in looking at these trends and influencing the strategic commissioning of services"[54], and Staffordshire commissioners raised concerns that since the shift of public health into local authorities they have placed 'limited priority' on children's and young people's mental health.[55] One witness suggested that transitional funding would be helpful to get early intervention services started:

    The one thing that would make a difference would be if there was some transitional funding that would help us to put in place, get up and running and get started some of the early intervention initiatives, some of the things that we know the voluntary sector can do very well but we don't have the money to give them to get started. If they apply to Children in Need or for lottery funding, it is time-limited; it is going to run out. We have to find the money to keep it going … Once the savings are made at the higher end, it will become self­financing. It is how you get it started that we are struggling with.[56]

49. Witnesses also described how the pathway approach, discussed in more detail in the next chapter, as a useful means of improving quality and efficiency, could also be helpful in terms of securing funding for early intervention services:

    If we are looking to fund the pathways—integrated pathways starting in universal services, in communities where needs present—the role of the third sector is clearer. It is harder to ignore the contribution that they can make if you are looking to fund the whole pathway; they are there. We have some examples in Derbyshire where we are able to do that ... It is something we would like to take forward, but it is not an easy climate within which to do that.[57]

Conclusions and recommendations

50. Early intervention services, including those delivered by voluntary sector organisations-whether these are drop-in services offering support to young people, parenting support programmes, or school-based interventions, can make a crucial contribution to preventing mental health problems from developing or escalating. However we have heard evidence of significant disinvestment in such services, despite evidence of their importance. Where they have been able to sustain services, some voluntary sector organisations report very fragile funding arrangements and great uncertainty over their future sustainability, despite evidence of growing demand for their services.

51. Health and Wellbeing Boards, and the transfer of public health budgets to local authorities, both represent significant opportunities for health issues to receive higher priority within local authorities. We have been told of some areas where these opportunities are beginning to be exploited, but this is patchy and progress remains slow. We have also heard that in times of financial constraint, some local authorities do not consider CAMHS early intervention services as "core business". We recommend that, given the importance of early intervention, the DH/NHS England taskforce should have an explicit remit to audit commissioning of early intervention services in local authorities, and to report on how best to improve incentives in this area. They should also look at the best mechanisms to provide stable, long term funding for early intervention services including those provided by voluntary sector partners.

37   Liverpool CAMHS Partnership (CMH0139), p2 Back

38   Tees, Esk and Wear Valleys NHS Foundation Trust (CMH0170) para 12.1 Back

39   Birmingham Children's Hospital NHS Foundation Trust (CMH0130), para 28 Back

40   Derbyshire Healthcare Foundation NHS Trust (CMH0191) pp7-8 Back

41   Solihull CAMHS (CMH0066) pp2-3 Back

42   Berkshire Healthcare NHS Trust (CMH0049) p2 Back

43   Q303 Back

44   London and South East CYP-IAPT Learning Collaborative (CMH0155) para 4.1.2 Back

45   Department of Health, Chief Medical Officer's annual report 2012: Our Children Deserve Better: Prevention Pays (October 2013) Chapter 3 p19  Back

46   Youth Access (CMH0092) para 3 Back

47   YoungMinds media release, 21 June 2014 Back

48   Department of Health, Statutory Guidance on Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies, March 2013 Back

49   Children and Young People's Mental Health Coalition (CMH0153), para 3.3 Back

50   Q292 Back

51   Q172 Back

52   North West London Commissioning Support Unit (CMH0211) p4 Back

53   Q285, q288 Back

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

55   Clinical Commissioning Groups within Staffordshire and Staffordshire County Council (CMH0134), para 2.2 Back

56   Q288 Back

57   Q291 Back

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Prepared 5 November 2014