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

6  Bridging the gap between inpatient and community services

167. Intensive services provided in the community can act as a bridge between inpatient services and community services, with the aim of preventing the need for an admission, or facilitating more swift discharge back to the community. These services are variously described as 'Tier 3.5', 'Tier 3+', 'assertive outreach' or 'intensive community' CAMHS services. Out-of-hours and crisis services are also essential for responding to children and young people who need urgent assessment and treatment; paediatric liaison services, based within acute hospitals rather than CAMHS services, can also act as an important link, where they are available. The evidence we have received has described the important contribution these services can make, but has highlighted the fact that provision of such services is highly variable, and has suggested that this might be a more useful focus for investment than inpatient services.

Out of hours/crisis services

168. Peter Hindley told the Committee that young people "will not necessarily need to be admitted if they are assessed quickly and can be linked into appropriate community service. You can often avert a crisis with a good out?of?hours assessment."[210] Dr Diwakar described the positive impact of an out-of-hours emergency response team which they have recently introduced in their area:

    Yesterday I was in our main hospital operations centre and there were seven children waiting on various wards for gateway assessments, waiting for a bed in tier 4 or waiting for social support. When you present in crisis there does need to be 24/7 access to an emergency response team, which we again have. It has only gone in in the last year. That again for me, as a paediatrician, has been a fantastic addition to the service because one can now react quickly to children and young people, whereas, before we had that service, a child would be admitted and I, as a paediatrician, would go and see them the next day. I do not have a lot of mental health training and would have to say, "I am sorry, you have to wait for the psychiatrist," … Because they only came twice a week, this wasted an in­patient bed and also proved to be very frustrating for the young person, who would often try and take their own discharge. In my view, the response, in terms of an emergency response team that can go to local hospitals, is going to be absolutely essential.[211]

169. However, according to the Royal College of Psychiatrists written evidence, provision of out of hours care varies across the country:

    The CAMHS Benchmarking report says that less that 40% of services offer rapid access through crisis pathways. In our survey of access to inpatient services 20% of respondents said that they did not have an out of hours service.

    Some areas were able to provide comprehensive out of hours services with CAMHS specialists providing first-line assessments but several reported difficulties in maintaining rotas of child and adolescent psychiatry higher trainees because of reduced numbers.[212]

170. The Black Country Partnership NHS Foundation Trust told us that, while provision of 24 hour cover to A&E services was well supported in one of the boroughs they serve, in another, there was no provision.[213] North West London Commissioning Support Unit told us that in their view,

    The very limited CAMHS available outside of office hours steers young people towards A&E and access to Out of Hours Service. Crisis or home treatment services for young people are not widely established with young people are being admitted to paediatric wards or CAMHS inpatient units. … Significantly enhanced Out of Hours CAMHS would be in a much better position to provide support to young people and the Police facing a potential Section 136 detention.[214]

171. Young people the Committee met with also described poor experiences of care in A&E departments-including poor knowledge of mental health, poor communication, lack of privacy, and lack of proper discharge arrangements - and on paediatric wards, including young people being cared for by security guards rather than clinicians. Discussing urgent out of hours care, young people from the Surrey County Council Youth Advisors group made the following observations:

    All members reported that urgent out of hours care was a very de-personalised service, and consisted of being told to go to A and E. In A and E the young people reported being assessed very slowly with little mental health support. One girl said she had overheard nurses saying she was bed blocking and promises of a mental health nurse coming to sit with her were never followed through.[215]

172. The GIFT partnership state that they have seen 'frustrations … in getting services when in crisis. Most CAMHS do not seem to be set up to respond in a safe and timely manner to crisis. These crises then escalate and can become very risky for children, young people and their families concerned, and any professional already working with them."[216]

173. In the written submissions received by individual parents, carers and service users, descriptions of crises formed a central part of the vast majority of submissions, and the complete absence of crisis support was highlighted as a key failing. Parents and carers reported being routinely advised to take their children to A&E in a crisis, which they regarded to be a wholly inappropriate environment for a distressed child. In many instances they had needed to call police and emergency care services for support. One parent highlighted that out-of-hours support in her area had been good until the 111 telephone helpline was introduced, after which point she had been unable to access suitable support. [217]

Paediatric liaison

174. Paediatric Liaison teams, which consist of mental health professionals based within the paediatric teams of acute hospitals, can make an important contribution in this area, as Dr Sebastian Kraemer, a paediatric liaison psychiatrist at the Whittington Hospital described to the Committee:

    Actually, where do you go in an emergency? You go to casualty. What happens in casualty if you are under 18? You go into a paediatric ward. If there is no mental health resource on that paediatric ward, then the child is an embarrassment, is frustrating paediatric staff, they are upsetting them and they are complaining. If there is a psychiatrist there—we have 24­hour-a-day psychiatry to the paediatric ward—they are grateful. They know it is part of their job to look after under-18s in crisis—deliberate self­harm and even psychosis. Some of them may need brain scans and the like, so they are in the proper place to be medically investigated. Then they will be pleased and they will do a good job. The paediatricians do a fantastic job in looking after seriously unhappy, disturbed young people because they have psychiatry on tap night and day. That is one point. That can only really survive if it is commissioned as part of a paediatric service. CAMHS is not going to provide this.[218]

175. Paediatric Liaison teams play a broader role as well:

    Paediatric liaison services are multi-disciplinary child and adolescent mental health services in the acute hospital setting. Their main focus is on: the acute management of psychiatric emergencies in the acute hospital (self-harm, delirium, acute disturbance of behaviour, acute psychosis); the identification and management of mental health problems in children with physical conditions (e.g. depression in the context of terminal illness such as cancer); the management of unexplained medical symptoms (e.g. conversion disorder, complex pain in the context of psychosocial difficulties); and the overall promotion of positive mental health in the acute hospital setting. Families may require help in coping with a newly diagnosed illness or managing a chronic illness. Mental health problems in parents interfere with parenting and may affect the mental health and coping of the children. (Paediatric Liaison email group, 2014). Identification of these issues early in the context of the medical treatment, significantly improves health outcomes and reduces costs. The RAID study demonstrated a saving of at least £4 for every £1 put into a liaison service for adolescents and adults (Tadros et al, 2013). Similar findings would be expected to be saved in a service aimed at children and adolescents.[219]

176. Dr Isobel Heyman explained the importance of this:

    Mental health disorders such as anxiety, depression and disruptive behaviour are much more common in children with long-term physical illnesses, such as diabetes or epilepsy, than in healthy children[4-7]. These mental health disorders impact significantly on children's development, functioning and quality of life, the implications of which persist into adulthood. Overall, mental illness has the same effect on life-expectancy as smoking, and more than obesity [8]. The mental health disorders often go unnoticed and untreated 9-11], and may also aggravate the physical health disorders. For example, depression in children with diabetes is associated with poorer control of blood sugar, increasing the risk for later serious complications such as loss of vision.[220]

177. However, while the Committee did hear of examples of good practice such as these, many highlighted the lack of paediatric liaison services. Sebastian Kraemer argues that "far too few paediatric departments have sufficient experience of timely and competent liaison. Despite a steady stream of national policy recommendations and research in the past decade there has never been a critical mass of first hand clinical knowledge of dedicated paediatric liaison teams in general hospitals." He points out that Paediatric Liaison services are often 'invisible' because they do not fall clearly within any of the 4 Tiers, and suggests they could be categorised as "Tier 3 ¾". Central and North West London NHS FT trust also highlight the difficulties around commissioning and funding such services:

    There is a lack of clarity regarding who the responsible commissioner is for [Crisis Response and Paediatric Liaison] services and as such these areas are not well developed within CAMHS services. Expectations are high that services will adapt and provide interventions in these areas, however Trusts are often not specifically commissioned to deliver these interventions. The fact that they are delivered via hospital A&E and paediatric wards and therefore serve non local patients is an added difficulty that is not supported by clear specifications and charging policies [221]

Tier 3.5 assertive outreach/intensive community services

178. Tier 3.5 assertive outreach/or intensive community services provide enhanced support for children and young people on the boundary between needing Tier 3 and Tier 4 services, as described by a service in Oxford:

    Provision of highly flexible and responsive community Outreach Service that provides a service 24/7.

    Team prevent admission and facilitate discharge

    Proactively 'tracking down' young people that are high risk but do not always attend appointments.

    Has proven to shorten length of admission from over 120 days to 50-70 days

    Provides stability to local placements for young people that are in care by working proactively with the Young person and wider care system by providing support, supervision and consultation to Children in Care Nurses, Social work staff, educational staff, residential care home staff.

    Keeps people closer to home.

    Diversion policy agreed with the police to ensure the prompt assessment of young people picked up by the police and reducing the need for mental health act assessments and holding in police stations. This has been seen a model of good practice and reduced the use of section 136 of the mental health act in under 18year olds in our area. [222]

179. Derbyshire Healthcare NHS Foundation Trust gave further details of a successful pilot in their area:

    Tier 3 Plus Service (CAMHS Crisis Home Treatment Service)

    The PCT commissioned the Derby City Tier 3 plus pilot in 1st March 2011. The funding provided was £85k per year which supported the development and establishment of a pilot tier 3 plus intervention by two workers. The full evaluation report has demonstrated a significant reduction in Tier 4 placements though the provision of enhanced community interventions. For those requiring admission, it has been shown to have a significant reduction in the actual length of stay. Evidence based assessment tools such as CGAS and HONoSCA have shown significant improvement in the overall clinical functioning and clinical outcomes for the young people who had accessed the service (ref: Young Persons Specialist Service Evaluation Report-Pilot 3+ Project 2013 Scott Lunn). [223]

180. However, almost two thirds (64%) of 96 CAMHS providers surveyed for the NHS England review said they did not have an intensive outreach team.[224] Derbyshire Healthcare NHS Foundation Trust report that their pilot has not received ongoing funding[225].

Commissioning incentives for Tier 3.5 services

181. A strong theme emerging from our inquiry is the need, wherever possible, to prevent admissions to Tier 4 services by providing more intensive Tier 3.5 services in the community, which have proved to be effective. However the Committee has been told that since the division of commissioning responsibilities between NHS England (responsible for commissioning Tier 4 services) and CCGs (responsible for commissioning Tier 3) there are now no incentives to fund such services, and that there are also fewer incentives for Tier 4 providers to discharge their patients in a timely manner. Dr Rao explained how the change in commissioning arrangements has the potential to undermine progress in developing Tier 3.5 services:

    Three years back, before the division from the CCGs and NHS England was brought about, the CCGs—then the PCTs—were asked to top-slice some amount of their budget to form a regional fund to create beds for the region because the demand was small but very intense. The idea then from that team, which provided the beds working along with the PCTs, was to create a tier 3+ model. It has been shown everywhere that it can decrease the amount of admissions to these in-patient beds. This was the same commissioning body which was proposing that we should work together with the PCTs to create a tier 3+ service, but, once this divide comes through from the CCG and NHS England, that same commissioning body will say that tier 3+ is a CCG problem and the CCG will say that a lack of beds is an NHS England problem.[226]

182. Worcester County Council describe an effective intensive community support service (Tier 3+) that they have worked hard to provide for young people on the threshold of needing inpatient services, despite the disincentives, but state that "It is unacceptable that CCGs are carrying the risk both in terms of the management of the patient and the inevitable financial risk of the additional investments we have made."[227]

183. Eating disorders provides another example of the difficulties in redirecting funding from inpatient to outpatient services. Dasha Nicholls, Consultant Psychiatrist at the Feeding and Eating Disorders Service at Great Ormond Street Hospital, states that "anorexia nervosa is the third commonest chronic illness of adolescence and has the highest morbidity and mortality of all psychiatric disorders", and that "eating disorders is one of the, if the not the, commonest reasons for CAMHS inpatient admission", but in fact "the best evidence based treatments are outpatient treatments".[228] South London and the Maudsley NHS Foundation Trust cite research suggesting that their eating disorder service, which results in some 68% of patients being well enough to be discharged after one year, in fact admits fewer than 10% of patients to inpatient care.[229] Despite this, Dr Nicholls states that "the majority of resources for eating disorders are directed towards inpatient care and adult services, both in the NHS and independent sector."[230] In their written submission, Birmingham Children's Hospital NHS FT describe an outpatient service they had planned for Eating Disorders, which has the potential to reduce demand on Tier 4 services, being 'shelved' because of the lack of a funding mechanism.

    Our strategy for Eating Disorders had been to develop an outpatient model of Family Based Treatment which we have previously successfully trialled. This is shelved as there is no funding mechanism, but given its potential to reduce demand for inpatient admission this seems short-sighted in managing the system more efficiently and effectively.[231]

184. Barnet Child & Adolescent Mental Health Service argue that the division of Tier 3 and Tier 4 commissioning may also contribute to delayed discharges:

    Unfortunately, what has been lost was the cost of these beds being the responsibility of the PCTs, which means we have also lost the financial incentive to keep admissions short and return children to the community for their treatment. We have seen lengths of stay increase considerably as all Tier 4 units are paid to keep their beds full and so there is a perverse incentive to keep admissions longer and not admit new patients at the risk of increasing overall workload for no benefit.

    Community services also don't have the PCTs demanding they discharge the young person as this function so far has not been taken on by NHS England. As a result Tier 4 services, which were already a precious resource, are less available now than they were before and indeed there have been occasions, and they seem to be increasing, when no Tier 4 bed was available in either private or NHS units across the country or the closest bed to London was in Edinburgh.[232]

185. Priory Healthcare, an independent provider of inpatient mental health services make the same point:

    Of additional concern to Priory is the lack of incentives for local trusts to facilitate early discharge. Local Tier 3 services were previously perceived as a re-investment of money and resource saved through reduced length of stay. Broadly speaking, however, such benefit is no longer being appropriately felt, with money following the patient through specialised commissioning, resulting in a rise in delayed discharge and bed blocking.[233]

186. The Minister told us that in his view, the current fragmented system of commissioning CAMHS was 'dysfunctional'[234]:

    The fragmented commissioning, to me, makes no sense. We have commissioning from local authorities, from schools, from CCGs and from NHS England. That, ultimately, cannot make sense …. I am looking to find ways in which we can align commissioning—ideally, ultimately, to pool the budget as far as is possible … There is an opportunity now to get a much more rational system, but I agree with your analysis.[235]

Conclusions and recommendations

187. We have heard that out-of-hours crisis services, paediatric liaison teams within acute hospitals, and Tier 3.5 assertive outreach teams can have a positive impact, including reducing both risk and length of inpatient admission; however availability of such services is extremely variable. The experience of care reported by those young people suffering a mental health crisis remains extremely negative.

188. It is clear from the evidence we have received that commissioning extra inpatient capacity alone will not be enough to alleviate the current problems being experienced in relation to Tier 4 services. Perverse incentives in the commissioning and funding arrangements for CAMHS need to be eliminated to ensure that commissioners invest in Tier 3.5 services which may have significant value in minimising the need for inpatient admission and in reducing length of stay. The Department of Health and NHS England must act urgently to ensure that by the end of this year all areas have clear mechanisms to access funding to develop such services in their local area, where this is appropriate.

189. Looking beyond this, we agree with the Minister that the current fragmented commissioning arrangements make "no sense", and are "dysfunctional". A key responsibility for the newly set up Taskforce will be to determine a way in which commissioning can be sufficiently integrated to allow rational and effective use of resources in this area, which incentivises early intervention. The Government has recently announced extra funding for early intervention in psychosis services and crisis care, which could include liaison services in A&E departments, and crisis resolution home treatment teams. We recommend that the Government ensures that a substantial proportion of this new funding is directed towards services for under-18s.

210   Q15 Back

211   Q164 Back

212   The Royal College of Psychiatrists (CMH0173) para 33-34 Back

213   Black Country Partnership NHS Foundation Trust (CMH0166), para 38 Back

214   North West London Commissioning Support Unit, (CMH0211) pp3-4 Back

215   CAMHS Rights and Participation Team (CMH0069) p2 Back

216   GIFT Partnership (CMH0159) para 1.4 Back

217   Personal experiences of CAMHS, written evidence, p7 Back

218   Q210 Back

219   Barnet Child & Adolescent Mental Health Service (CMH0142) para 2.1 Back

220   Dr Isobel Heyman (CMH0138) para 2b Back

221   Central and North West London NHS Foundation Trust (CMH0132) p6 Back

222   Oxford Health NHS Foundation Trust (CMH0230) para 21 Back

223   Derbyshire Healthcare Foundation NHS Trust (CMH0191) p5 Back

224   NHS England Report pp129-130 Back

225   Derbyshire Healthcare Foundation NHS Trust (CMH0191) p6 Back

226   Q157 Back

227   Worcester County Council (CMH0160), para 11 Back

228   Dr Dasha Nicholls (CMH0105), p1 Back

229   South London and Maudsley NHS Foundation Trust (CMH0227) p4 Back

230   Dr Dasha Nicholls (CMH0105), p1 Back

231   Birmingham Children's Hospital Foundation Trust (CMH0130) para 10 Back

232   Barnet Child & Adolescent Mental Health Service (CMH0142), para 4.1 Back

233   Priory Healthcare, (CMH0145) para 4.3 Back

234   Q445 Back

235   Q342 Back

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© Parliamentary copyright 2014
Prepared 5 November 2014