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

8  National priority and scrutiny

237. Discussing the views we had heard on the current state of CAMHS services, the Minister responded as follows:

    I would accept all the propositions that you put to me, that the system, to me, looks rather dysfunctional with all this different commissioning, that there have been poor decisions about funding in localities and that there needs to be a complete recognition across the whole system that mental health really must be treated equally—that parity of esteem is not just a bit of rhetoric but has to be delivered in practice. You cannot do that just by exhortation. You have to make sure that the levers deliver it. That is why I think it is so important that you get access to the data. Information drives change. If you have an understanding of what is actually happening across the system, rather than the fog we have worked in up until now in mental health, you can start to put pressure on the system to change. That has to be combined with standards of access and waiting times that exist in physical health but do not exist in mental health. That has to change, and it is starting next year.[280]

    I cannot begin to justify failures of care that result in a youngster being sent off somewhere else around the country, or not getting access to early intervention in psychosis, or whatever the issue might be, so I have impatience about this, just as all of you do. It is complex. The problem has been made worse, in my view, by some fairly irrational decisions around the country about disinvestment in children's mental health, and indeed mental health more generally in some areas—not across the entire country, because there are areas that are doing, in my view, exactly the right thing. I think there needs to be a sense of a national imperative that this changes.[281]

238. Many of our submissions agreed that CAMHS now needs to be given greater priority at a national level. According to the Tavistock Centre for Couple relationships

    …The lack of centrally driven policy development, performance management and targeted funding together with funding reductions both as a result of the efficiency drive with the NHS and the reductions in local authority budgets are, we feel, to a large extent responsible for the current challenges and difficulties in service provision.

    It is difficult therefore to imagine that improvements in children's mental health and psychological wellbeing and the services required to meet children's needs will not require a reiteration of the importance of CAMHS by central government, backed up by a new national programme of service development that is adequately resourced and effectively performance managed.[282]

239. Birmingham Children's Hospital Foundation Trust state that there is a need for "a major rethink on the part of policy makers to make children's mental health the priority it needs to be." In their view, this should include:

    Clear expectations and national standards for a 21st Century CAMHS

    Levels of funding which reflect need.

    Clarification and monitoring of levels of staffing and skills needed to provide services[283]

240. National minimum service specifications for Tier 3 services were recommended by several witnesses, and the Committee endorses this, alongside the need for thorough audit to ensure that CAMHS services are meeting these.

241. Turning to the Minister's focus on levers within the sytem to deliver improvement in CAMHS, it seems clear that the system's current levers for ensuring standards-including commissioners and the CQC-have not delivered improvements in CAMHS services in a consistent way. CCGs and Local Authorities manage their own spending priorities, and in the absence of national targets, guidance and service specifications, many LAs and CCGs have struggled to prioritise CAMHS within current financial constraints, with the resulting impact of worsening services, as described by both providers and service users submitting evidence to this inquiry. In the words of one commissioner:

    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.[284]

242. NHS England told us that "with respect to the CCGs, it is more tricky because, in a sense, we cannot tell CCGs what to do in the world in which we work at the moment, but we have an assurance system which invites CCGs to consider mental health across the whole lifespan, and NHS England is now revisiting the financial levers that we have at our disposal."[285] Several submissions call for improvements in consistency and accountability of CAMHS commissioning:

    It is clear to us that there is a damaging lack of clarity on responsibility and accountability for the effective commissioning of CAMHS. An up to date strategy, grounded in the realities of the pressures facing public services and recent reforms is needed. Better guidance for local agencies is needed to ensure roles and responsibilities are clear.[286]

    We recommend that … a working party is set up to review current commissioning arrangements for all child mental health services to ensure sufficiently funded and resources services are providing effective delivery of evidence-based interventions.[287]

243. We were also told that "CAMHS receives very little if any scrutiny from the Care Quality Commission"[288]

    I have never seen a CAMHS team inspected in the same way as I see other parts of the public sector inspected. We have concerns about our tier 4 providers. We are currently dealing with several complaints about them and we have shared them with NHSE, but we are the people writing the complaints letters and talking to the families; we are having the conversations behind closed doors about, "At what point do we go to the Care Quality Commission about a particular provider that we are concerned about?"[289]

    Our experience in Essex is that we have not had much involvement from CQC in children's mental health services. We have had more advice from our Ofsted colleagues, but really a very poor service from CQC. We have had to be very proactive ourselves in dealing with complaints to NHS England and sorting out the complaints and scrutiny ourselves … We have detected that they do not see it as part of their brief. [290]

244. In response to this, the Minister told us that "the truth is that we do not have a full enough picture yet about the variability in quality around the country."[291] However, he believed new arrangements at the CQC would be stronger:

    It may well have been a fair assessment, but I think it is changing. Now that we have someone with a dedicated responsibility for mental health … I do not think there is any risk that children's mental health services will be ignored in the future. They are introducing a much more rigorous inspection regime …That gives us an opportunity, as I indicated earlier, to put the spotlight on mental health and to really identify good practice, but also unacceptable practices, in a way we have never been able to do before.[292]

245. The CQC have provided detail on their new inspection regime, which will from now on include an inspection of CAMHS services in all inspections of mental health trusts:

    We began to pilot our new style inspections in NHS mental health services in January 2014, with a full roll-out from October 2014. The new style inspection defines core services for each type of organisation, which will always be inspected where they are provided. CAMHS has been designated as a core service for NHS mental health trusts. We have carried out twelve inspections using this new approach and will carry out a further four inspections this autumn.[293]

246. However, the CQC were not able to give us information on which CAMHS services, or how many, had been inspected between 2009 and 2013.[294]

247. It is also essential to put in place the right levers to prioritise early intervention in children's mental health, as Professor Dame Sally Davies, the CMO, explained:

    I have seen the newspaper reports and I have heard the stories, and it is unacceptable for children who need secure accommodation to end up in police cells or even miles away. So that does need sorting. But that is a small problem … if we did more at the preventive early end we wouldn't need so many beds. Some of this lack of beds is because the children are not being picked up and dealt with when they present, so they spiral downwards.[295]

    …..anything that you can do to help shift the debate away from putting a sticking plaster on something that is wrong to moving to prevention and early intervention would be very welcome. We, as a nation, need to shift to that. I also welcome any support you can give to raising the children's agenda up the priority list because they are our future. Economically, we are sunk if we don't make sure that our children come through all right.[296]

248. Following the conclusion of our evidence sessions, in October this year the Department of Health published Achieving Better Access to Mental Health Services by 2020. This confirmed the Government's commitment to funding 50 new inpatient CAMHS beds, and announced further investment for early intervention services for psychosis, and for crisis services more generally, including liaison psychiatry in A&E departments for all ages, and crisis resolution home treatment teams. It also gives further detail on proposed access targets, which will include a target that 50% of those experiencing a first episode of psychosis will receive referral to a NICE-approved care package within two weeks of referral, 75% of people referred to the Improved Access to Psychological Therapies programme will be treated within 6 weeks of referral, and 95% will be treated within 18 weeks of referral.[297] However it is not clear how waiting targets will apply to CAMHS services more broadly, nor the extent to which funding for crisis services will apply to services for under-18s.

Conclusions and recommendations

249. It is clear that there are currently insufficient levers in place at national level to drive essential improvements to CAMHS services. These have received insufficient scrutiny from CQC and we look to review progress in this area following their new inspection regime. The Minister has argued that waiting time targets will improve CAMHS services but we recommend a broader approach that also focuses on improving outcomes for specific conditions in children's and adolescents' mental health.

250. We recommend the development, implementation and monitoring of national minimum service specifications, together with an audit of spending on CAMHS. We recommend that the Department of Health/NHS England taskforce look to remove the perverse incentives that act as a barrier to Tier 3.5 service development and ensure investment in early intervention services. There must be a clear national policy directive for CAMHS, underpinned by adequate funding.

280   Q445 Back

281   Q445 Back

282   Tavistock Centre for Couple Relationships (CMH0025), para 2 Back

283   Birmingham Children's Hospital NHS Foundation Trust (CMH0130), para 42 Back

284   Q292 Back

285   Q456 Back

286   National Children's Bureau (CMH0146) para 2.1  Back

287   London and South East CYP-IAPT Learning Collaborative (CMH0155), para 6.2 Back

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

289   Q277 Back

290   Q278 Back

291   Q389 Back

292   Q425 Back

293   Additional written evidence submitted by Care Quality Commission (CMH0235) p1 Back

294   Additional written evidence submitted by Care Quality Commission (CMH0235) p1 Back

295   Q35 Back

296   Q59 Back

297   Department of Health, Achieving Better Access to Mental Health Services by 2020, October 2014 Back

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Prepared 5 November 2014