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


4  Outpatient specialist CAMHS services (Tier 3)

52. Outpatient specialist CAMHS services are community mental health services for children and young people with more severe problems who need more specialist treatment than can be provided by Tier 2 services.

The view from CAMHS services

53. Many providers of CAMHS services described the situation in their own areas with great honesty and frankness. We are including a selection of quotes from these descriptions not with the intention of singling out any particular Trusts for criticism, but as a means of illustrating the present difficulties facing CAMHS services and the variation around the country. Dr Myers of Cornwall Partnership NHS Foundation Trust gave the following account of Tier 3 CAMHS services in Cornwall:

    Over the last five or six years, since we have been collecting records, our referral rates have gone up approximately 20% year on year to the extent where we are currently commissioned to see around 2,000 referrals, but we have 4,000 a year. This has meant that we are necessarily having to prioritise those who have the most urgent and pressing need, and we have no capacity for earlier intervention and very little capacity for seeing those perhaps with the less life­threatening or urgent risky presentations but for whom we could also do very useful pieces of work, such as those with neurodevelopmental disorders. It has also meant that the staff are feeling extremely run-ragged. There is increasing sickness, a lot of burn­out and we absolutely recognise that there are increasing waits. It is not okay. We do not want that for our children and young people, but we have to just keep prioritising. So there are cancellations and times when at any one time we might be trying to manage situations where there is a need to have an in­patient bed but there aren't any. That takes us away from more of the front­line work that could possibly be preventing admissions.[58]

54. Barnet Child and Adolescent Mental Health Service reported an average 26.5% increase in all referrals to CAMHS services, and a 45% increase in self-harm rates[59], and Derbyshire Healthcare NHS Foundation Trust stated that "the service has experienced a huge increase in referrals they receive and accept into service"[60] Warwickshire County Council report that

    Overall referral rates are increasing: from April 2014 to November 2014 these increased further by over 500 from 3,100 to 3,621.

    Rates of Self-harm have increased substantially over the last two years. At Q2 in 2012/13 rates of self-harm were at 107 for the year to date. By Q2 in 2013/14 rates of self-harm were already at 231for the year to date.

    ASD (autism spectrum) assessment referrals are reported to be increasing year on year. Data is unavailable due to difficulties in recording.[61]

55. Discussing the impact of increased demand, Black Country Partnership NHS Foundation Trust argues that meeting demand within the context of a "significant shortfall in funding" leads to long waiting times, and interventions being shorter than required:

    There is a significant shortfall in funding for specialist CAMHS services at all levels to deliver the required activity and meet the demand placed on it. This leads services to provide within the available resource, often leading to long waiting times which impacts on accessibility into the service, shorter than required interventions and without a developed skill mix and workforce.[62]

56. Cornwall Partnership NHS Foundation Trust give a similar picture:

    Due to a change in the case mix referred i.e. more risky and unwell youngsters, there has been a knock-on effect on the ability to assess and treat non-urgent cases (mainly neurodevelopmental disorders such as autism, ADHD). This has led to an increase in internal waiting times. [63]

57. A further impact of increased demand in some areas has been increased referral thresholds, meaning services are now accepting fewer referrals, prioritising those with the highest levels of need:

    There has been a clear increase in the threshold for access. This has been monitored through the common point of entry team (developed 2 years ago) which has demonstrated that as referrals increase, the number of referrals signposted to alternative services has also increased.[64]

    Many services report continuously increasing complexity of cases arriving at CAMHS, including higher levels of self-harm. Combined with reduced staffing and disinvested services, this is driving up thresholds for acceptance of referrals and resulting in junior staff holding increased levels of clinical risk.[65]

    Birmingham has mainly managed the overall increase in referral rates by tightening referral criteria and signposting less serious cases to other services, only accepting more serious presentations. Our referral acceptance rate has reduced from 75% to 65%."[66]

58. Barbara Rayment of Youth Access, which represents voluntary sector providers, told us of an extreme example, where "in some areas, it has been reported that CAMHS will not see any young person unless they have attempted at least one suicide."[67] The British Psychological Society state that 71% of professionals responding to their survey said that their service had tightened its acceptance criteria for a referral to the CAMHS services, and "even more concerning was that 88% said there were insufficient other services to signpost non-accepted referrals to."[68]

59. Problems described in our submissions were not confined to difficulties in accessing services, but also to quality. Birmingham Children's Hospital NHS Foundation Trust report that while its membership of QNIC (Quality Network for Inpatient CAMHS) and QNCC (Quality Network for Community CAMHS) gives it regular peer reviews of the quality of its service and "review reports are generally very good", they are "becoming increasingly challenged to maintain quality given workload and complexity."[69] Solihull argue that in the course of the last decade, funding increases, some of them ringfenced "led to clear improvements in service delivery and outcomes", with many CAMHS teams becoming NICE guidelines compliant. However, they go on to argue that "Over the last 3 years, we have lost most of the gains we had made":

    The improvements in quality measured through NICE guideline compliance, post interventional outcomes and patient satisfaction surveys seem to indicate either a stalling in quality improvements or deterioration. Although the principle of expecting increased efficiency, and productivity in a business is a good one, blanket application of recurrent efficiency savings of 5% or more on an underdeveloped service like CAMHS, with its areas of unmet and partially met need- like that of looked after children, impact of parental mental illness, offending and substance misuse, needs of ethnic minority and hard to reach populations has caused significant damage to developing services.[70]

The view from service users

60. Unsurprisingly, children and young people and the parents of service users provided a similar view on the state of Tier 3 services. In written evidence to us one parent described the profound impact that a long wait to access services can have on a young person and their family:

    From initial referral to concluding interview was 8 months. Combined with the previous wait for Family Therapy and CBT, a whole school year had now been missed. We would now struggle to get the 5 GCSE's that would open the doors to further education. It seems that these waiting times are not unusual, and yet the impact on people's lives seems forgotten. 13 weeks waiting is a full school term. For a child with ADHD, this means a term of disrupted classroom, a term of a teacher stressed, 30 other children suffering in the classroom. And at home, the parent is suffering, endlessly trying to support the child, apologising for problems caused, trying to protect the rest of the family, exhausted, unable to go out to work. For a teenager, a term is more GCSEs lost, more friends lost.[71]

61. At their meeting with the Committee, young people raised the following issues relating to CAMHS Tier 3 services:

    Tightened referral criteria meaning mental health problems have to escalate to serious levels before help is given;

    The importance of ownership of treatment and choice, which is not always given;

    Insufficient information for young people about CAMHS services and mental health more generally, including online;

    Specific examples of poor service provision including lack of respect, privacy, and continuity of carer, and lack of regular medication review.

62. In the written submissions received from individual parents, carers and service users, poor access to service, unclear referral thresholds and long waiting times were frequently raised as issues. Further, parents and carers stressed that because of the length of waiting times for an assessment, the child's or adolescent's problems generally became more entrenched and harder to treat, families were under sustained pressure, and it shifted the focus of care to crisis management, rather than preventative measures. Overall, key criticisms centred on:

    Confused access and pathways and excessive waiting times

    Lack of understanding of the needs of children and their families, including insufficient specialist expertise to recognise complex comorbidities

    Lack of multiagency communication and administrative failures

    Limited availability of appropriate treatment and support, including inpatient treatment and specialist interventions for treating complex comorbidities

    Abrupt transition to adult services

    Low awareness about mental illness in young people.[72]

63. The majority of submissions from parents and carers raised issues about the referral process for CAMHS, how decisions were made about who was accepted by CAMHS, and where they could go if they were not referred for an assessment. Many reported having been initially refused for an assessment, and offered no other form of support; their child's mental health problems had subsequently escalated.[73] Seeking care was often described as a battle: one parent wrote that

    My experience of having a child with mental health issues is that as well as battling with the pain and stigma of having a mentally ill child, it is also a draining and difficult battle to try and get the right help.[74]

64. Parents also felt that they themselves were given very little guidance or support by CAMHS services about how best to help their child.[75]

65. Jody Tranter, inclusion manager at a London primary school, gave the following overview:

    The CAMHS service is buckling under an ever-increasing demand for its services

    As a result, most referrals result in an assessment which almost always results in the case being closed

    It would appear that only the most disturbed children are eligible for any sort of intervention from CAMHS

    There is a large and significant gap in the mental health provision for distressed, disturbed and unhappy children.[76]

66. Drawing on their engagement work with young people, Dr Cathy Street and Dr Yvonne Anderson made observations about young people's comments about CAMHS staff, both positive and negative:

    ….large numbers of young people continue to report unhelpful attitudes from some CAMHS staff and some report quite worrying behaviours from their therapists.

    "It would be great if the workers at CAMHS would actually help, listen to me and respect me. Not treat me like I'm a mental idiot, I hate CAMHS for the way I have been treated. I haven't been given much of a choice in my treatment and it seems it was all made behind my back. Overall, everything needs improving." Young person: Puzzledout

    Of course children and young people also have many good things to say about CAMHS.

    "The workers are very understanding, and listen to everything you say, which is something I really appreciate." "I have had a lot of people involved, from nurses and doctors on the wards, to now in the local CAMHS team. They have been all as helpful as possible and always willing to listen" Young people: Puzzledout[77]

67. Dr Street and Dr Anderson also describe research they have published in this area showing that children and young people find it hard to complain about poor experiences of CAMHS

    that children and young people are afraid or reluctant to complain about poor service from CAMHS. They understand the culture of the NHS is not positive regarding negative feedback and they do not wish to cause trouble. In cases where a young person is motivated to complain, the process may be opaque and obstacles placed in their way. We question how services are ever to improve in such a climate.[78]

68. They also describe access problems, arguing that feedback from young people has been the same for the past ten years:

    Hundreds of children and young people have given their feedback to local services via Puzzledout since it was launched in 2011. In reviewing this feedback the most striking feature was that they are saying the same things they were saying ten years ago. Children and young people want better access, services that are more acceptable and appropriate for them and greater involvement in their own care. It is sad and inexcusable that we are still hearing the same views and still failing to act on even the most simple of them-such as extending opening hours or redesigning waiting areas.[79]

69. Young sessional workers from the GIFT partnership (a group which has been commissioned by NHS England to support the participation of children and young people in the CYP-IAPT programme) highlighted the difficulties that young people may find in accessing CAMHS services:

    Honestly, for young people who may be reliant on their working parents or public transport, the service offers help in places that cover a whole area where some people struggle to access it. This could potentially make a huge impact on whether the young person goes to treatment or feels it's too much effort, as much as they want help. For example, a YP has to ask one of their parents to take time off work to take them to a session, or a YP has to travel for quite some time to their nearest service.[80]

70. Healthwatch Northamptonshire report that they recently ran an engagement campaign with children young people and families to inform plans to redesign CAMHS in their area, and describe some of the issues raised by young people and families:

    Access is a problem: We heard very widespread concern about the limited availability of Child and Adolescent Mental Health service in Northamptonshire. People said services are usually good once they have been able to access the service, but the issue is getting access. Many people said that waiting times for CAMHS are unacceptable. While waiting times in Northamptonshire may be average (according to the local Clinical Commissioning Groups), the sense is from the people we spoke to that this can feel like a very long time when there are urgent health mental health needs. This was a view echoed by nearly all the children and young people who spoke to us about CAMHS. For some this has resulted in having to seek diagnosis privately.

    "Everywhere I go there is a long waiting list and it's hard to cope with when I am suffering from depression"

    Problems with access to counselling services and early intervention/preventative services: Children and young people are not aware of where to go to for support. Children and young people with urgent needs talked to us about being turned down or contact with services not being followed up. Several people talked about a lack of continuity of care. We heard from one young woman who had 12 counsellors in 4 years.

    Many children and young people told us that they don't get the right support at the right time-not just CAMHS, but other services. Several young people and parents described the "struggles" or "fights" they have had to get services. Many people talked about the high level of need they have to demonstrate in order to get any support. The impact this has on the lives and wellbeing of children, young people and families is significant, at times overwhelming, and makes it difficult to plan for independence and is life-limiting in the long term.[81]

Improving Tier 3 services

71. Some provider organisations described efforts to redesign services to improve quality and efficiency which had led to improvements, but often they argued that these improvements have been limited by, or are under threat from, continuing increases in demand and funding constraints. Birmingham Children's Hospital NHS Foundation Trust report that by implementing a service transformation model called CAPA (Choice and Partnership), they have in fact successfully reduced waiting times since 2010:

    In 2010 like many other CAMHS we had long waiting lists, up to 1000 patients waiting for treatment with approximately 450 waiting over 18 weeks. Only 55% of our patients were seen for treatment in 18 weeks. We have successfully implemented CAPA (Choice and Partnership Approach) to manage capacity, demand and flow through the system of referrals. Now 100% of patients are seen within 18 weeks with a 4 week average for first appointments (Choice) and an 11.4 week average for commencing treatment (Partnership).

72. However they go on to state that they "are at risk of losing some of the gains we have made and increased workloads are impacting on staff."[82]

73. Berkshire Healthcare NHS Trust report that it has redesigned its services to develop specialist pathways for ADHD, ASD and Anxiety and Depression, and has increased its efficiency to allow it to see more young people this year than last year. However there has still been a significant increase in waiting times over the past 3 years, with over 700 young people waiting more than 12 weeks for a treatment intervention, although referrals are triaged on receipt and urgent cases seen within 24hr and high risk cases seen within 1-3 weeks.[83]

74. North East London NHS Foundation Trust report that despite 'unparalleled' increase in referrals, their threshold for access has remained unchanged:

    We maintained waiting lists within the national targets and we managed the increase in referrals by increasing throughput through services, adopting briefer therapies and by bringing in triage functions to teams. We also make more use of parenting groups and ADHD follow-up clinics which are not run by consultants in order to reduce the consultant work load. However, we are at stretch point and would not be able to accommodate further increases in demand in the context of reduction in income without having to cut some of the services we deliver[84]

75. NHS England state it is developing a waiting times project to deliver its Mandate objective on parity of esteem to bring waiting times for those with mental health issues in line with those in other services,[85] a point the Minister reiterated during oral evidence.[86] Barbara Rayment of Youth Access felt that such a target could help, were it accompanied by the resources needed to achieve it.[87] However, Peter Hindley of the Royal College of Psychiatrists said that he would be wary about waiting time targets, as they can create perverse incentives including internal waiting lists, and felt that it might be better to introduce targets for commissioners aimed at lowering the prevalence of specific conditions.[88]

76. Specialist treatment pathways and clinics for specific conditions were cited as a helpful approach, though not without problems:

    The development of specialist clinics as a QIPP[89] has been an attempt to maintain high quality care that meets NICE guidance. This has been achieved within the pathways. However this has been at the expense of greater waiting times of non-urgent cases as referral numbers increase. There is concern that the focus on the specialist pathways /clinics has left the locality community teams which manage the most complex and risky young people under resourced, with less contribution to joint agency work from Local Authority agencies. There is a danger that overall the service provided to these people reduced. There has for example been a decrease in the number of clinicians involved with each young person.[90]

77. Liverpool CAMHS partnership has developed a "comprehensive CAMHS pathway" which attempts to bring better integration between the Tiers, and reports positive outcomes both in terms of reduced referrals to higher Tier services, and in outcome and satisfaction measures.[91] North East London report that they are currently integrating CAMHS and community paediatric services:

    Our CAMHS services and community paediatric services are presently undergoing integration. Pathways like the neurodevelopmental pathway will comprise of complete joint working between paediatricians and CAMHS clinicians. Integration also means greater joint working with the primary workforce such as health visiting and school nurses. This creates the opportunity for up skilling of the Tier 1 workforce. Primary mental health workers work with health visitors and school nurses to enable them to be more able to accurately identify mental struggles in their client groups but also to intervene early as well as having clear referral routes into CAMHS.[92]

78. Many organisations also reported contributing to the CORC programme. The Child Outcomes Research Consortium (CORC) is a not-for-profit learning collaboration dedicated to finding the best ways to collect and use outcome data to create the highest quality services for children, young people and their families. CORC report that

    Membership now includes members from over half of UK NHS CAMHS, with an increasing cohort of voluntary sector members. Members collate outcome information from children and their families, primarily from self- report questionnaires (patient reported outcome measures- PROMS) focused on symptomology, general wellbeing, impact and patient reported experience measures (PREMS) focusing on therapeutic relationships, access and satisfaction with service. Members send aggregated pseudonymised data to the CORC central team once a year to allow the team to produce a report that compares their outcomes with those of relevant others in the consortium[93]

79. A strongly positive development within CAMHS in recent years has been the introduction of the Improving Access to Psychological Therapies programme (CYP-IAPT), described by the Government as a 'transformational programme' to improve access to psychological therapies within CAMHS services:

    The programme does not create separate services, but seeks to transform existing services by making a modest investment in infrastructure including IT, participation and in workforce, training service leaders in best practice demand management systems, and training a number of supervisors and therapists in each partnership in evidence based treatments for self-harm, depression, anxiety, eating disorders and conduct problems. It mandates the collection of routine outcome monitoring.[94]

80. CYP IAPT currently works with services covering 54% of the 0-19 population with a target of working with services covering 60% by 2015. It is the Government's aim that all of England will be involved by 2018.[95] While CYP IAPT has been widely welcomed as a positive step, written submissions to the Committee suggest that this programme does not represent a total solution to current issues within CAMHS, and that some areas implementing the programme are struggling to deliver improvements in the context of increased demand and reduced funding, as NHS England acknowledges:

    Some services are already able to demonstrate improved efficiency through using CYP IAPT methodology. However, it is important to note that the programme is being put in place during a time of cuts and cost improvement plans for CAMHS by both local authority and NHS which is impacting on the ability of some services to take full advantage of the programme …[96]

81. Central and North West London Foundation Trust report that services have benefited from the CYP-IAPT over the past two years, but argue that this is "limited" and "comes with its own challenges particularly around data."[97] Professor Peter Fonagy, National Clinical Lead for the CYP-IAPT programme, states that:

    Cuts to CAMHS budgets at CYP IAPT partnerships since 2010 include Hackney (76% reduction), Derby (41% reduction), Bedford (27% reduction), Redcar & Cleveland (27% reduction), Ealing (19% reduction), Kensington and Chelsea (19% reduction), Westminster (19% reduction), Durham (13% reduction), Newcastle (13% reduction), North Somerset (10% reduction), and Leeds (9% reduction)[i]. One CYP IAPT site has reported a reduction in a fifth of staff due to cuts. Another site has reported that all the staff trained in Parenting through the CYP IAPT programme have been made redundant due to cuts. Another Trust has reported having to adjust to the cuts by reducing numbers of experienced staff and replacing them with more junior staff.

    … Some services have responded to budget cuts by raising thresholds, meaning that a child or young person is only seen if their mental health problem is judged to be at a raised level of severity. This increased threshold also compromises the ability of services to accept self-referral.

    Capacity is limited by Clinical Commissioning Groups wanting to manage referral rates and impose Quality, Innovation, Productivity and Prevention targets.

    However well we deliver the CYP IAPT programme, existing services still need experienced, evidence-trained, and appropriately supervised staff on the ground.[98]

Commissioning specialist outpatient CAMHS services (Tier 3)

82. Tier 3 services are commissioned by CCGs, and NHS England have a responsibility for assuring and supporting CCGs.

83. In their written submission to the inquiry, NHS England state that "only 6% of Mental Health Spend is on Children and Young People (Kennedy, 2010). CAMHS is under resourced. According to research only 25% of children with a diagnosable mental health problem receive a specialist service."[99] YoungMinds have recently published data obtained through Freedom of Information requests suggesting that 77% of CCGs which submitted data have frozen or cut their CAMHS budgets between 2013-14 and 2014-15. (34 reported having cut their budgets, and 40 reported having frozen their budgets).[100] Evidence of disinvestment in recent years is also borne out in the NHS Benchmarking Review of CAMHS 2013 (NHS Benchmarking Network, 2013).[101] Discussing funding for CAMHS in general terms, North West London Commissioning Support Unit argue that "CAMHS is usually a small part of a large Adult Mental Health and the operational, contractual and funding requirements are too easily overlooked"[102]:

    It is overlooked and neglected not by intention but because it is mostly bundled with adult mental health services. Our adult mental health services have enormous volumes, enormous difficulties and their own possible inquiry into the problems they have in relation to budgetary considerations and providing safe treatments and places for people. Children, I think, in the health service traditionally have been brought somewhat belatedly to the table … The agenda in health is enormous. Unless you have people banging on about children and their mental health needs—and indeed other needs—they do not get heard, if I am frank. [103]

    Historically, CAMHS has always been the poor relation to adult mental health. For example, in adult mental health we have had adult mental health tsars and more ministerial ambassadors, but that has not really been reflected in the children's world.[104]

84. Solihull provided the following view:

    For those of us working in Child and Adolescent Psychiatry, and being witnesses to this unfolding crisis, the first step is to stop further deterioration in the situation. This is only possible if we can have certainty about CAMHS funding structures and amounts. Commissioning arrangements regarding all tiers of CAMHS have to be clarified. The quick way to give some financial certainty would be to ring fence CAMHS budgets again, so that they are not an easy target for cash strapped local councils and acute trusts.[105]

85. Witnesses also referenced changes to the tariff deflator as further evidence of a lack of parity of esteem. The Chief Medical Officer argued:

    Everything is a question of prioritisation. I am told that Monitor and NHS England have said that the tariff next year should be minus 1.5% for the acute sector and minus 1.8% for the mental health sector, and the difference relates to the need for £150 million for the acute sector to address the Francis inquiry issues. That ignores the Winterbourne View issues or the Francis issues in mental health, let alone a historical lack of focus in the area.[106]

86. Norman Lamb agreed that mental health and CAMHS in particular faced funding problems:

    I think there are funding issues. I have made it pretty clear, I think, in the time I have been Minister, that there is an institutional bias against mental health, and it has not had its fair share of funding. Within mental health there is a big question mark as to whether children's mental health gets its fair share …Is it really rational that 6% of the mental health budget is applied to children and young people when we know that a very significant proportion of mental health problems start in the teenage years?

    The other thing is that we have to address the imbalance in levers and incentives in the system that always disadvantage mental health. If you have a very potent 18­week waiting time standard in physical health but nothing in mental health, that will dictate where the money goes from the local CCGs.[107]

    [Resourcing] In my view, it is very variable around the country, and I think this is what was exposed superbly by the YoungMinds survey. It is great that they did it, because we have to identify which areas are doing it well and which are doing it badly. That survey revealed that there are loads of areas around the country that are increasing investment in children's mental health services, but there are far too many that are reducing funding for an area that, to me, ought to be seen in every area as a priority. That view and the evidence from the survey apply both to CCGs and to local government.[108]

    There is an issue about ring­fencing here. I have not reached any conclusion, but I think ring­fencing was withdrawn in 2008. Question: do we need to look at that?[109]

CHALLENGES FOR COMMISSIONERS

87. The opening chapter of this report discussed the difficulties commissioners currently face because of the lack of up to date information. The complexity of current commissioning arrangements for CAMHS has also been described as a problem:

    The disaggregated CAMHS commissioning arrangements have increased the risk of fragmented service delivery, conflicting commissioning intentions, post-code lottery of provision, confusing communication for providers, and poor value for money. Locally this is being addressed for tiers 1-3 through a CAMHS commissioning project.[110]

88. Many commissioning and provider organisations argue that the restructuring of the NHS in 2013 has made arrangements even more complex, and while some, including Derbyshire Healthcare NHS Foundation Trust and Staffordshire commissioners, report robust efforts to improve joint commissioning,[111] the prevailing picture is one of complexity and difficulty, as Islington CAMHS describe:

    Located between local authority, education and health commissioners, CAMHS runs a tightrope of fragile commissioning arrangements so that initiatives are too often short term, with an uncertain funding base and reliant on collaborations between commissioning agencies who themselves have cost pressures which they are often unable to control. The time and energy spent by CAMHS service leaders in negotiating and securing funding for services from a wide range of stakeholders is extraordinarily wasteful of expertise that should be used on more direct project work within the services they manage and supervise.[112]

89. Central and North West London NHS Foundation Trust argue that they are "experiencing a concerning and damaging breakdown in structures, processes and communication and a clear message that our CAMHS experience and expertise is no longer valued in commissioning and planning", and that the issues they identify are resulting in "collective confusion, duplication of work and are compromising the quality and safety of services".[113]

90. North West London Commissioning Support Unit raise the shortness of CAMHS contracts as a difficulty for commissioners and for providers:

    Currently CAMHS contracts are very short with an annual re-negotiation which consumes vast amounts of staff resources, both for providers and commissioners. New service specifications and performance frameworks barely have time to be constructed before they are subject to review and further change.[114]

    We have a floor of people endlessly going round this contracting round… It is important to get it right, but you end up being a contracting person rather than somebody commissioning services for children who have mental health problems. They should run for two or three years and then you might have some chance to see what works.[115]

91. However Jane Lunt of Liverpool CCG felt that it was possible to work around this:

    You just renew your annual contracting process and refresh your key performance indicators, outcomes, quality schedule and so on. Within that, the key specification could be for three years … We try not to allow the contractual process to become the commissioning process. The commissioning process is a cycle that includes the contractual process, but that is just a nuts-and-bolts function. Your commissioning process is understanding your local needs assessment, looking at what services you have—where your gaps and strengths are—and then commissioning and determining what you need as services to meet the needs of your population.[116]

MONITORING THE PERFORMANCE OF CAMHS SERVICES

92. CCGs have an important role in monitoring the performance of CAMHS services and ensuring they are delivering high quality, value for money services within their own areas. Central and North West London NHS Foundation Trust argue that in their view "performance management meetings are inconsistent. In some areas we have none and therefore no formal ways to raise difficulties and concerns and seek support/partnership solutions."[117] In oral evidence, Steve Buckerfield of North West London Commissioning Support Unit described quarterly performance meetings with providers and stated that they currently receive data on volume of patients, types of treatments and waiting times, and that each year they are adding more questions about treatments and evidence base, but whilst attempting to keep the information burden manageable.[118] Steve Buckerfield also argued for the importance of securing feedback from children and young people, and went on to point out that CCG patient committees often do not have young people included on them, and that in his view local authorities and CCGs should collaborate better on this.[119]

93. Despite the progress that has been achieved in this area through initiatives such as CYP-IAPT and CORC, North West London Commissioning Support Unit also argue that "the adoption and performance reporting of outcome focused practice across CAMHS has been slow and would benefit from significant encouragement".[120] The Evidence Based Practice Unit argue that "safety as an aspect of CAMHS has been largely overlooked and needs to be better built into recording systems and performance management."[121] Dr Jenny Taylor of the British Psychological Society agreed that there was a greater need to focus on outcomes in CAMHS, to ensure that services are actually making a difference to children and young people's mental health:

    We are talking a lot about access to services, but we also need to make sure that the services we are delivering are effective and making a difference …we have not spoken about as much is ensuring that the interventions that we offer when children and young people do come to our services make a difference to whether or not they return and deliberately self­harm or whether they actually attempt suicide.

    We have, for example, a lot of NICE guidance about children's and adolescent mental health services. One of our colleagues who spoke earlier talked about the need for commissioning groups to ensure that there were certain provisions. That would be a starting point, making sure that CAMH services are providing, at the least, what the NICE guidance recommends needs to be provided, as opposed to emphasising needs for numbers of staff, for example, or particular disciplines … We are collecting far more of that sort of data than we have done previously, but still in many trusts the data they are required to provide to the commissioners is not that data: it is how quickly they are seeing people and how many people they are seeing, which, as a colleague said to me the other day, is a bit like simply looking at whether the post office are picking up letters very quickly and how many they are picking up, but not checking where they are going.[122]

IMPROVING CCG COMMISSIONING

94. When asked how effectively they felt CCGs were performing in their functions, neither NHS England nor the Department of Health raised concerns:

    CCGs are just over a year old. My personal view—I know it was David Nicholson's view as he left NHS England—is they have done remarkably well in their first year. Of course, across 211 or 212, there is a variation in terms of level of performance, but I genuinely believe that having general practitioners driving CCGs, collaborating with local authorities and other partners, has made a real difference in terms of some of the big decisions that needed to be made around changing commissioning patterns within localities. I think that is very exciting and welcome. That is the good news.

    There clearly is variation in terms of the extent to which CCGs are prioritising mental health, and, within that, children's mental health. That has to be addressed through the assurance relationship between NHS England and CCGs over a period of time. [123]

95. Professor Sir Bruce Keogh told us he had "very little to add" to Mr Rouse's assessment, and that "clearly you would expect there to be some variation, because CCGs are, in the grand scheme of things, still relatively immature; they are forming."[124]

96. However, North West London Commissioning Support Unit argued that "expertise in CAMHS commissioning is in very short supply with as a result service development, innovation and invest to save activity, significantly under-represented in the sector."[125] Essex County Council state that it has become increasingly hard for commissioners to find out about best practice since the abolition of the CAMHS national support service, and state that in redesigning their service they have expended considerable effort in contacting other areas for information, which could have been reduced if there were national opportunities for this.[126] She even stated that it had been very valuable to look at the written evidence submitted by different areas to this inquiry.[127]

97. While there is already a wide range of NICE guidance relevant to CAMHS services, covering treatments for different conditions, witnesses suggested a need for further guidance setting out "at least a bare minimum" of what a CAMHS service should provide. Dr Myers stated that in her view,

    It would be helpful if there was absolute national guidance on at least a bare minimum that you are meant to provide because, locally, commissioners can make a choice about what to invest in or not to invest in. So, for me, there needs to be an absolute bottom line, "You must get this level."[128]

    In specialised commissioning, there are service specifications that provide exactly that sort of guide to the local area teams as to what to commission. I do not see the same for CCG commissioning, where it very much depends upon the CCG's own professional knowledge of the sorts of services available. I think one of the solutions is to provide that sort of guidance, so not to break up the service. I do not think CCGs are failing us and there are many very good examples, but I do not think they have enough guidance … It should come from the NHS and there should be discussion then about how best to allocate resources. Resources per head of population should be tied into acuity, complexity and dependencies. There is quite wide variation at the moment. [129]

98. At our oral evidence session the Minister told us that he planned to develop a programme of CAMHS "exemplar" sites, from which examples of best practice could be disseminated.[130] NHS England also sent us further information about the CCG mental health leadership programme, run by NHS England, which includes a day's learning on commissioning CAMHS, with best practice examples. They also mentioned the Mental Health Intelligence Network, which there is an 'ambition' to extend to children's and young people's services.[131] In their memoranda, NHS England also state that the CYP-IAPT programme is currently working on developing a new Tier 2 and Tier 3 service specification:

    The Children's and Young People's Improving Access to Psychological Therapies team in NHS England (CYP IAPT) is working with partners to support improved commissioning framework for Children and Adolescent Mental Health Services (CAMHS) framework which facilitates closer working together of all commissioners-NHS England, CCGs, Local Authorities (including social care and education). The programme is creating a new Tier 2 and 3 specification to support commissioning of evidence-based, outcomes-focussed CAMHS. This work will take into account the outcome of the Tier 4 review. The CYP IAPT Programme is developing resources to support better integrated working across counselling and Tier 3.[132]

Problems with specific aspects of Tier 3 CAMHS

99. Our inquiry received over 200 submissions of written evidence, and the breadth of issues covered in these provides an excellent illustration of the complexity of CAMHS services and the different problems faced by the children and young people who use them. We received submissions from many different professional groups, some advocating for specific therapeutic approaches. We also received submissions covering a wide range of specific mental health and neurodevelopmental problems; and highlighting a number of different groups who are particularly vulnerable to mental health problems. Within the limited time available to this inquiry, we have not been able to address the all the specific challenges and problems raised in the written evidence relating to individual conditions and specific vulnerable groups, or different therapeutic approaches; but in this section we provide an overview of some of the issues raised, and we recommend that the Department of Health/NHS England taskforce address these more fully.

100. We received written evidence describing problems with services for CAMHS children and young people specific conditions including Autistic Spectrum Disorders (ASDs), ADHD, Obsessive Compulsive Disorder, learning disabilities and other disabilites, and Eating Disorders.[133] Concerns that were frequently raised included delays in diagnosis; access problems and lack of sufficient specialist knowledge of specific conditions within CAMHS.[134] Several groups highlighted the importance of condition-specific pathways as a means of improving access and standards.[135] Submissions from parents frequently raised similar problems, and written evidence from provider organisations agreed that long delays were often occurring in the assessment and treatment of children and young people with neurodevelopmental disorders.[136]

101. Our written submissions, and our discussions with young people themselves, also highlighted the specific groups of children and young people who are particularly vulnerable to mental health problems, but whose needs may not currently be being adequately addressed by CAMHS services. These included children and young people in the care system, and those who have been adopted or fostered;[137] homeless young people;[138] asylum seekers and recent immigrants;[139] and lesbian, gay, bisexual and transgender young people.[140] Submissions were also received outlining the particular needs of bereaved children.[141]

Transition

102. Difficulties with transition from CAMHS to adult mental health services was raised both in the Committee's session with young people, and in the written submissions received from individual parents, carers, and service users. The GIFT young sessional workers made the following observations:

    Focusing just on transitional period between CAMHS to adult mental health services for me was traumatic. I felt like there wasn't a solid structure of guideline to ensure despite my age there was a service that enabled me to not slip back into crisis. I'm not sure what can realistically be done to tackle this issue but maybe something along the lines of a merge between services or a specialist link worker role to make the transition smoother and less detrimental.

    Upping the age is something a lot of young people would agree needs to be done. Although the transition is smooth, adult services are very different from children's services. At 18, YP should be treated as a young adult, not an adult. [142]

103. Young people from the Surrey County Council Youth Advisors group also described issues in this area:

    All the young people who had transitioned to Adult Services reported needing more information on the differences between CAMHS and Adult Services, especially surrounding the different thresholds, and the support that could be provided if thresholds were not met. One member reported a very good transition where he kept his CAMHS worker for a couple of months to enable the transition to be smoother. However he also said that the turnover of staff in adult services was very high and had not had the opportunity to develop any relationships with them.

    One particularly shocking story was reported of a young person who was an inpatient on her 18th birthday and was made to move from the Children's ward to the adult ward on that day.[143]

104. The young people the Committee met with also described problematic experiences with transition, particularly for those young people for whom it coincided with moving away from home to university. The CYPMHC describe transition from CAMHS to Adult mental health services (AMHS) as a "perennial problem", which features in all of the previous reviews of CAMHS.[144] The Royal College of Psychiatrists report that "transition from CAMHS to AMHS continues to be an issue of concern in many areas."[145] NHS England state that "transition from child centred to adult services is currently poorly planned, poorly executed, and poorly experienced. This can lead to the "cliff edge" where support falls away, the young person disengages, and may present as their first episode of transition acutely in crisis to an adult Emergency Department."[146] Closing the Gap: Priorities for essential change in mental health, identifies transition from CAMHS to appropriate adult services as a priority for action, and NHS England state that they will be developing a transition service specification for CCGs and Local Authorities.[147]

Perinatal mental health services

105. As well as problems for young people reaching adulthood, a strong theme we heard throughout this inquiry was the importance of early intervention to support mental and emotional health in the perinatal and infant period. The Children's and Young People's Mental Health Coalition was one of many organisations to highlight this:

    The first 1,001 days of a baby's life are critical and this developmental window is the best time to help parents and carers support their baby and help ensure healthy brain development. If necessary put in place interventions that help ensure that babies are securely attached and get off to the best start in life.

    Infant mental health provision has historically been very patchy with some areas having good provision, and others having virtually nothing. About 1 in 10 women suffer from post natal depression, which can impact on the mother's ability to become securely attached to their child; but provision for these women is very poor.

    Like CAMHS, infant mental health provision requires different levels of service. It should include universal services that promote healthy parent-infant interactions; services for infants who are displaying early signs of mental health problems, and specialist perinatal mental health provision which supports both mothers with mental illnesses and their babies.[148]

106. Dr Amanda Jones of North East London NHS Foundation Trust argued that "perinatal Services are rare in the UK and, where available, often small and poorly resourced."[149] In oral evidence, Dr Jones went on to argue that such services should be seen as an essential part of healthcare, in the same way that specialised physical health services are:

    Someone needs to say that the services have to be there, just like you expect an A and E to be available if you have a car accident or you expect a neonatal intensive care unit to be available if you have a premature baby. You should say, "I expect in this area that to be available." If you have bipolar affective disorder and you are at risk of breaking down very quickly after birth, you don't want just to be with ordinary adult mental health; you want to be with a specialist perinatal psychiatrist who knows about the medication and has managed that during your pregnancy, who knows about what to do if you need admission. You need specialist knowledge, not just general psychiatry.[150]

107. In addition to the written submissions we received from charities and interest groups focused on this area[151], the lack of perinatal and infant services was identified by many CAMHS service providers as a problem. The Black Country Partnership NHS Foundation Trust state that there is no perinatal or infant mental health service provision in their area,[152] and Cornwall Partnership FT have highlighted perinatal and infant mental health as a service for which they have been unable to secure funding.[153] Central and North West London NHS Foundation Trust state that they have "major concerns" about the "lack of coherent commissioning and specific funding for early infant and perinatal mental health", and go on to say that "we have cases where under 5s are already struggling in the environment of nursery or school and have limited access to services that may be able to help."[154] Derbyshire Healthcare NHS Foundation Trust told us:

    There is no Infant Health Service locally despite increasing evidence regarding the impact of early environment, attachment difficulties, domestic abuse and parents struggling with mental health problems on their children. Previously successful projects such as Building Bridges lost funding and whilst Family Nurse Partnership and increased numbers of Health Visitors are to be welcome they may not have knowledge regarding infant mental health. Our CAMHS CYIAPT Parenting Therapy groups and others with training in attachment, Theraplay and skills in working with Parents with Mental Health problems are not being utilized yet in developing Services further for families of young children.[155]

108. According to the Maternal Mental Health Alliance, Pregnant women and new mothers across almost half of the UK do not have access to specialist perinatal mental health services, potentially leaving them and their babies at risk.[156] When we discussed perinatal and infant mental health with the Minister, he agreed that "there is nothing more important" than this. [157]

Conclusions and recommendations

109. Providers have reported increased waiting times for CAMHS services and increased referral thresholds, coupled with, in some cases, challenges in maintaining service quality. In the view of many providers, this is the result of rising demand in the context of reductions in funding. Not all services reported difficulties-some state that they have managed to maintain standards of access and quality-but overall there is unacceptable variation.

110. Young people and their parents have described "battles" to get access to CAMHS services, with only the most severely affected young people getting appointments; they also described the devastating impact that long waits for treatment can have.

111. We heard many positive examples of efforts within CAMHS to improve efficiency and quality-these included the Choice and Partnership approach, the introduction of pathways for managing specific conditions, and development of more integrated services. The CYP-IAPT programme was also highlighted as a positive development in improving access and quality. However, even amongst those providers implementing quality and efficiency improvement programmes, there was concern that improvements were being stalled or even reversed because of increasing demand and reduced funding.

112. Whilst demand for mental health services for children and adolescents appears to be rising, many CCGs report having frozen or cut their budgets. CCGs have the power to determine their own local priorities, but we are concerned that insufficient priority is being given to children and young people's mental health. We recommend that NHS England and the Department of Health monitor and increase spending levels on CAMHS until we can be assured that CAMHS services in all areas are meeting an acceptable standard. We welcome recent funding announcements for mental health services but we remain concerned and recommend that our successor committee reviews progress in this area.

113. CCGs are responsible for commissioning Tier 3 services. Evidence to our inquiry has detailed numerous difficulties facing the commissioners of CAMHS services. These include the annual contracting rounds, which some argued was a distraction from more strategic commissioning; the lack of reliable and up-to-date information on children's and adolescent mental health services and CAMHS; and the complex web of different organisations involved in the commissioning and provision of CAMHS. A particular complaint was the lack of guidance available on best practice.

114. We have heard that a stronger focus on evidence-based practice and outcome measurement, including safety, is needed. Collaborations such as CYP-IAPT have driven improvements in this area, but commissioners must take a stronger lead in ensuring that services are actually making a measurable difference to children and young people's mental health, and in ensuring that this focus is not overlooked in the drive to improve access.

115. Commissioners of CAMHS services undoubtedly face a difficult task in collaborating across a complex web of other commissioners, and overseeing a varied patchwork of different types of providers to attempt to commission a seamless CAMHS service. They also face challenges in securing sufficient funding for this sadly de-prioritised service. However, CCGs hold ultimate responsibility for commissioning community CAMHS services, and we feel that there is a clear need for CAMHS commissioners to be given further monitoring and support from NHS England to address the variations in investment and standards that submissions to this inquiry have described. We recommend NHS England provides an action plan detailing how it plans to do this.

116. We heard from witnesses that national service specifications are required, to set out minimum acceptable levels of community CAMHS services, and we understand that Tier 2 and 3 service specifications are now being developed. We recommend that these specifications should set out what reasonable services should be expected to provide. They should cover specific clinical areas including ASDs, perinatal mental health, and eating disorders, as well services which currently fall between the Tiers, including out-of-hours, outreach and paediatric liaison. We recommend that the taskforce should carry out and publish an audit of whether services are meeting these minimum standards.

117. We welcome the Minister's commitment to establishing 'Pioneer sites' of best practice within CAMHS, and we again urge the taskforce to consider the evidence submitted to this inquiry in helping to identify high performers. In our view supporting other commissioners and providers to improve will require more than simply holding up examples of good practice. Detailed analysis should be undertaken to establish how these areas have managed to secure these improvements, in order to make these approaches easier to implement in other areas, and pioneer sites should make an explicit commitment to evaluate and share their learning.

118. In addition to the universal concerns expressed about CAMHS services, we also received written submissions highlighting problems with CAMHS services being experienced by children and young people suffering from particular conditions, or from especially vulnerable groups of society. Specific conditions included OCD, ASDs, ADHD and Eating disorders; vulnerable groups included children and young people in the care system, and those who have been adopted or fostered; homeless young people, asylum seekers and recent immigrants; lesbian, gay, bisexual and transgender young people; and bereaved children and young people. The breadth of different conditions and different populations covered in our written submissions is indicative of the complexity but also the importance of the task facing CAMHS services. This inquiry does not have the scope to consider all of these issues individually, but again we recommend that the Department of Health/NHS England taskforce takes full account of the submissions we have received, and the wealth of information they contain.

119. Transition from CAMHS to adult mental health services has been described by NHS England as a "cliff edge", and the stories we heard from young people bears this out. We are encouraged to see that the Government is taking steps to address this by identifying transition as a national priority, and by supporting the development of a national service specification for transition. We will seek an update on progress towards this in six months.

120. As well as the transition to adulthood, a crucially important time for promoting good mental health is the perinatal and infant period. The Minister agreed that "nothing is more important than this". However, while the written submissions we received suggested that while some areas are providing good services for parents and babies, many are not. There is unacceptable variation in the provision of perinatal mental health services, and we recommend this is addressed urgently. Service specifications should make clear that these services must be available in every area.


58   Q148 Back

59   Barnet Child & Adolescent Mental Health Service (CMH0142)  Back

60   Derbyshire Healthcare Foundation NHS Trust (CMH0191) p7 Back

61   Warwickshire County Council (CMH0182) para 3.1 Back

62   Black Country Partnership NHS Foundation Trust (CMH0166), para 7 Back

63   Cornwall Partnership Foundation NHS Trust (CMH0189), para 6 Back

64   Berkshire Healthcare NHS Trust (CMH0049) p2 Back

65   London and South East CYP-IAPT Learning Collaborative (CMH0155) para 4.1.7 Back

66   Birmingham Children's Hospital NHS Foundation Trust (CMH0130), para 21 Back

67   Q5 Back

68   British Psychological Society (CMH0133) p4 Back

69   Birmingham Children's Hospital NHS Foundation Trust (CMH0130) para 12 Back

70   Solihull CAMHS (CMH0066) p1 Back

71   Personal Experiences of CAMHS, written evidence, pp 3-4 Back

72   Personal Experiences of CAMHS, written evidence p 2 Back

73   Personal Experiences of CAMHS, written evidence p3 Back

74   Personal Experiences of CAMHS, written evidence p2 Back

75   Personal Experiences of CAMHS, written evidence p5 Back

76   Jody Tranter (CMH0147) Executive summary Back

77   Dr Cathy Street and Dr Yvonne Anderson, The GIFT Partnership (CMH0178) p3 Back

78   Dr Cathy Street and Dr Yvonne Anderson, The GIFT Partnership (CMH0178) p4 Back

79   Dr Cathy Street and Dr Yvonne Anderson, The GIFT Partnership (CMH0178) p3 Back

80   GIFT Partnership (CMH0159) para 1.2 Back

81   Healthwatch Northamptonshire (CMH0212) pp1-2 Back

82   Birmingham Children's Hospital NHS Foundation Trust (CMH0130), para 7 Back

83   Berkshire Healthcare NHS Trust (CMH0049) p1 Back

84   North East London NHS Foundation Trust (CMH0037) p1 Back

85   NHS England (CMH0193), para 17 Back

86   Q388 Back

87   Q21 Back

88   Q26 Back

89   Quality, Innovation, Productivity and Prevention initiatives Back

90   Berkshire Healthcare NHS Trust (CMH0049) pp2-3 Back

91   Liverpool CAMHS Partnership (CMH0139) pp1-2 Back

92   North East London NHS Foundation Trust (CMH0037) p2 Back

93   Child Outcomes Research Consortium (CORC) (CMH0141) Para 2.3-2.4 Back

94   NHS England (CMH0193) para 18 Back

95   Department of Health (CMH0154) Para 16; NHS England (CMH0193) para 18 Back

96   NHS England (CMH0193) para 18 Back

97   Central and North West London NHS Foundation Trust (CMH0132) para 4 Back

98   Professor Peter Fonagy (CMH0216) para 4 Back

99   NHS England (CMH0193) para 3 Back

100   YoungMinds media release, 21 June 2014 Back

101   NHS England, Child and Adolescent Mental Health Services (CAMHS) Tier 4 Report, 10 July 2014, p14 Back

102   North West London Commissioning Support Unit, (CMH0211) pp2-3 Back

103   Steve Buckerfield, Q251 Back

104   Barbara Herts, Q251 Back

105   Solihull CAMHS (CMH0066), p4 Back

106   Chief Medical Officer, Q30 Back

107   Q387 Back

108   Q417 Back

109   Q456 Back

110   Warwickshire County Council (CMH0182) para 6.1 Back

111   Clinical Commissioning Groups within Staffordshire and Staffordshire County Council (CMH0134), para 2.2; Derbyshire Healthcare Foundation NHS Trust (CMH0191), p12 Back

112   Islington CAMHS (CMH0077) p1 Back

113   Central and North West London NHS Foundation Trust (CMH0132) para 3 Back

114   North West London Commissioning Support Unit, (CMH0211) p3 Back

115   Q258 Back

116   Qq 333-334 Back

117   Central and North West London NHS Foundation Trust (CMH0132) p4 Back

118   Q274 Back

119   Q278 Back

120   North West London Commissioning Support Unit, (CMH0211), Executive Summary  Back

121   Evidence Based Practice Unit (EBPU) (CMH0161), para 4.4.3 Back

122   Qq188-189, Q197 Back

123   Q422 Back

124   Q422 Back

125   North West London Commissioning Support Unit, (CMH0211), p3 Back

126   Essex County Council (CMH0078) para 3.4 Back

127   Q265 Back

128   Q184 Back

129   Q184 Back

130   Q342 Back

131   Additional written evidence submitted by NHS England (CMH0233) Back

132   NHS England (CMH0193) Para 6 Back

133   See for example, Act Now For Autism (CMH0205), National Autistic Society (CMH0163), UK ADHD Partnership (CMH0048), Educational Rights Alliance (CMH0117), OCD Action (CMH0152), Can't Go Won't Go (CMH0168). Contact a Family (CM0148) Back

134   ibid Back

135   See, for example, OCD Action (CMH0152), Act Now For Autism (CMH0205), National Autistic Society (CMH0163),) Back

136   See for example, Hampshire Parent Carer Network (CMH0149), Wiltshire Parent Carer Council,(CMH0184) Kent Parent Carer Forum (CMH0095), Black Country Partnership NHS Foundation Trust (CMH0166), para 17-18, Cornwall Partnership Foundation NHS Trust (CMH0189) para 6-7 Back

137   See for example, Derbyshire County Council Children Younger Adults Dept. (CMH0192), TACT (CMH0055), British Association for Adoption Fostering (CMH0082), Adoption Leadership Board (CMH0231) Back

138   See, for example, Centrepoint (CMH0061) Back

139   See, for example, Barnet Child & Adolescent Mental Health Service (CMH0142) Back

140   See, for example, Jan Bridget (CMH0014), METRO (CMH0156) Back

141   Childhood Bereavement Network (CMH0150), Shirley Potts, Director of Regional Development for Child Bereavement UK (CMH0100) Back

142   GIFT Partnership (CMH0159) para 4 Back

143   CAMHS Rights and Participation Team (CMH0069) p2 Back

144   Children and Young People's Mental Health Coalition (CMH0153) para 6.5.1 Back

145   The Royal College of Psychiatrists (CMH0173) para 38 Back

146   NHS England (CMH0193) para 41 Back

147   Department of Health, Closing the Gap: Priorities for essential change in mental health , January 2014, p26  Back

148   Children and Young People's Mental Health Coalition (CMH0153) para 6.1 Back

149   Amanda Jones, (CMH0221) p5  Back

150   Q221 Back

151   See, for example, All Party Parliamentary Group for Conception to Age 2 (CMH0214), Maternal Mental Health Alliance (CMH0076), Association of Infant Mental Health (CMH0101), Bliss (CMH0046) Back

152   Black Country Partnership NHS Foundation Trust (CMH0166),, para 11 Back

153   Cornwall Partnership Foundation NHS Trust (CMH0189), para 8 Back

154   Central and North West London NHS Foundation Trust (CMH0132) para 5 Back

155   Derbyshire Healthcare Foundation NHS Trust (CMH0191) p7 Back

156   http://everyonesbusiness.org.uk/  Back

157   Q434 Back


 
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© Parliamentary copyright 2014
Prepared 5 November 2014