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



1.  There are serious and deeply ingrained problems with the commissioning and provision of Children's and adolescents' Mental Health Services. These run through the whole system from prevention and early intervention through to inpatient services for the most vulnerable young people. We welcome the announcement of the joint NHS England /Department of Health Children and Young People's Mental Health and Wellbeing Taskforce, as it endorses one of our central conclusions, that problems with CAMHS are broadly based and not simply confined to inpatient Tier 4 services. Many of the recommendations in this report are therefore directed towards this taskforce as it begins its work. In addition to this, we recommend that the taskforce takes full account of the wealth of information contained in the written submissions received by this inquiry, including, in particular, submissions from service users, from their parents and representatives, from individual clinicians working in CAMHS, from provider organisations and from commissioners. We plan to review the progress of the taskforce early in 2015.(Paragraph 7)


2.  The Committee is deeply concerned that the most recent ONS data on children's and young people's mental health is now ten years old, as up-to-date information is essential for the safe and effective planning of health services. We welcome the Government's commitment, made during the course of this inquiry, to fund a repeat of the ONS prevalence survey. It is essential that this survey is not a one-off, but is repeated on an ongoing basis. We recommend that the Department of Health/NHS England taskforce adds the issue of the quality of ongoing data to its terms of reference.(Paragraph 23)

3.  Not only is there a lack of data on children and young people's mental health, but also a worrying lack of comprehensive and reliable information about children's and adolescents' mental health services, including referrals, access and expenditure. In the words of the Minister, CAMHS services have been operating in a "fog", and efforts to improve data availability have been subject to delays. This is unacceptable. Ensuring that commissioners, providers and policy-makers have access to up-to-date information about all parts of CAMHS services-from early intervention up to inpatient services-is essential. We recommend that this is a priority for the Department of Health/NHS England taskforce.(Paragraph 24)

CAMHS as a whole system

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

Early intervention mental health services (Tier 2)

5.   We recommend that, given the importance of early intervention, the DH/NHS England taskforce should have an explicit remit to audit commissioning of early intervention services in local authorities, and to report on how best to improve incentives in this area. They should also look at the best mechanisms to provide stable, long term funding for early intervention services including those provided by voluntary sector partners. (Paragraph 51)

Outpatient specialist CAMHS services (Tier 3)

6.  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.(Paragraph 112)

7.  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.(Paragraph 115)

8.  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. (Paragraph 116)

9.  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.(Paragraph 118)

10.   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.(Paragraph 120)

Inpatient CAMHS services (Tier 4)

11.  It is wholly unacceptable that so many children and young people suffering a mental health crisis face detention under s136 of the Mental Health Act in police cells rather than in an appropriate place of safety. Such a situation would be unthinkable for children experiencing a crisis in their physical health because of a lack of an appropriate hospital bed and it should be regarded as a 'never event' for those in mental health crisis. In responding to this report we expect the Department of Health to be explicit in setting out how this practice will be eradicated.(Paragraph 160)

12.  Written submissions to this inquiry have described a situation where despite the move to national commissioning over a year ago, NHS England has yet to 'take control' of the inpatient commissioning process, with poor planning, lack of co-ordination, and inadequate communication with local providers and commissioners. While many of the difficulties NHS England is now seeking to address may be a legacy from previous arrangements, it has not, in our view, sufficiently prioritised these problems. We note that in addition to the new capacity that is being funded, NHS England is recruiting more case managers to give them better control over the commissioning process, but we are disappointed that during its first year as a commissioner of inpatient services, many of the perceived benefits of national planning have not been realised, and NHS England has instead presided over a system which has resulted in children being sent hundreds of miles to access care. We intend to review NHS England's progress addressing these problems early in 2015.(Paragraph 162)

13.  As a first step in improving its commissioning of Tier 4 services, we recommend that NHS England should introduce a centralised inquiry system for referrers and patients, of the type that is already in operation for paediatric intensive care services.(Paragraph 163)

14.  We believe that education is crucial to protecting the life chances of the especially vulnerable young people who need inpatient treatment for mental health problems, particularly as in some cases these admissions may last many months. It is essential that clear standards are set for the quality of education provision in inpatient units, and that there is clear accountability and ownership for ensuring that these standards are upheld. As a first step towards this, we recommend that OFSTED, DFE and NHS England conduct a full audit of educational provision within inpatient units as a matter of urgency.(Paragraph 166)

Bridging the gap between inpatient and community services

15.  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.(Paragraph 188)

16.  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. (Paragraph 189)


17.   We consider that awareness of mental health issues, including their relationship to normal child development, conduct issues, and impact on education, is important and we recommend the Department for Education looks to including a mandatory module on mental health in initial teacher training, and should include mental health modules as part of ongoing professional development in schools for both teaching and support staff.(Paragraph 210)

18.  . We recommend that the Department for Education conducts an audit of mental health provision and support within schools, looking at how well the guidance issued to schools this year has been implemented, what further support may be needed, and highlighting examples of best practice. OFSTED should also make routine assessments of mental health provision in schools. (Paragraph 211)

19.   We recommend that the Department for Education consult with young people, including those with experience of mental health issues, to ensure mental health within the curriculum is developed in a way that best meets their needs.(Paragraph 212)

Digital culture, social media, bullying and cyberbullying

20.  We have not investigated the issue of internet regulation in depth. However, in our view sufficient concern has been raised to warrant a more detailed consideration of the impact of the internet on children's and young people's mental health, and in particular the use of social media and the impact of pro-anorexia, self-harm and other inappropriate websites, and we recommend that the Department of Health/NHS England taskforce should take this forward in conjunction with other relevant bodies, including the UK Council for Child Internet Safety.(Paragraph 227)

21.   We recommend that the Department of Health/NHS England taskforce should also investigate and report on the most effective ways of supporting CAMHS providers to do this.(Paragraph 228)

22.   We recommend that as part of its review of mental health education in schools, the Department for Education should ensure that links between online safety, cyberbullying, and maintaining and protecting emotional wellbeing and mental health are fully articulated.(Paragraph 229)

23.  We recommend clear pathways are identified for young people to report that they have been sent indecent images of other children or young people, and that support is provided for those who have been victims of image sharing. Pathways should also be established for children and young people who have experienced bullying, harassment and threats of violence. (Paragraph 230)

General practice

24.  We ask Health Education England, together with the GMC and relevant Royal Colleges, to provide us with a full update on their plans for GP training in children's and adolescents' mental health. (Paragraph 236)

National priority and scrutiny

25.  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.(Paragraph 249)

26.  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.(Paragraph 250)

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Prepared 5 November 2014