8.According to the joint DfE and DH statutory guidance on Promoting the health and well-being of looked-after children, all looked-after children and young people who enter care should have an initial health assessment by a registered medical practitioner. Looked-after child reviews should subsequently take place every six months with an Independent Reviewing Officer (IRO), social workers and foster or residential carers. Health and well-being should form part of these discussions.
9.In addition a Strengths and Difficulties Questionnaire (SDQ), a brief emotional and behavioural screening tool, should be completed annually for every child in care. Despite this Ofsted told us that SDQs are “rarely” used to maximum effect:
Most local authorities inspected since the publication of the revised guidance in March 2015 were unable to complete initial health assessments of children after they enter care within the required timeframe consistently. A small number of local authorities were unable to provide data on this statutory requirement.
10.Lisa Harker, Director of Strategy, Policy and Evidence at the NSPCC, told us that the SDQ is just a starting point and that a “fuller” mental health assessment should be undertaken by a mental health professional for those children who receive high scores in the SDQ. The NSPCC’s written evidence stated that:
Although we support a system that uses SDQs in a consistent manner, they are not mental health assessments and they will not provide the overarching mental health insight that is essential upon entry into care.
11.The National Children’s Bureau also told us that initial health assessments on entering care are “highly variable and often poor”. It recommended that assessments of looked-after children should be completed by a qualified mental health professional when entering care.
12.The regular assessment of looked-after children and young people’s mental health and well-being was raised by Teresa Latham, a foster carer. Ms Latham told us that assessment of mental health needs should take place throughout a child’s time in care rather than just at the beginning. She explained that “the child that you have for the first three to six weeks of placement is not the child that you will have after six weeks. They settle in and then you see the real child.”
13.Current methods of assessing children and young people’s mental health and well-being as they enter care are inconsistent and too often fail to identify those in need of specialist care and support. Initial assessments are rarely completed by qualified mental health professionals with an appreciation of the varied and complex issues with which looked-after children may present.
14.We recommend that the Government amends the statutory guidance to make clear that an SDQ should be completed for every child entering care as a starting point. In addition all looked-after children should have a full mental health assessment by a qualified mental health professional. Where required this should be followed by regular assessment of mental health and well-being as part of existing looked-after children reviews.
15.CAMHS offer assessment and treatment when children and young people have emotional, behavioural or mental health difficulties. The services they provide differ depending on the local area. We received a substantial amount of evidence on the capacity of CAMHS to respond and treat looked-after children and young people.
16.In our first evidence session Sarah Brennan spoke of the high numbers of young people being turned away from CAMHS because they did not “fit the medical criteria of having a diagnosed mental health problem”. David Graham, National Director of the Care Leavers Association, supported this view by adding that the level of assessment which CAMHS used was “too high”. The result of high thresholds for treatment can mean that young people are placed at the end of lengthy waiting lists. One young person we met in our informal meeting told us that “doctors refer young people to CAMHS, and then the young person receives a message saying that you are not a priority”, they added “this is disgusting and a huge self-esteem blow”.
17.Christine Malone, a foster carer, told us that CAMHS will only see a child when they are in a “permanent settled placement”. The young woman in Ms Malone’s care said that she had been waiting for CAMHS for over two and a half years but had been unable to access services because she had moved thirteen times during that time period. Despite the statutory guidance stating that should “looked-after children should never be refused a service, including for mental health, on the grounds of their placement”, this refusal of CAMHS to see children without stable placements was described in several pieces of written evidence. The National Adoption & Fostering Service said that “CAMHS LAC (looked-after children) services will often want to wait until a child is ‘stable’ before assessing or treating”. The reluctance to assess or treat young people without a stable placement largely stems from “uncertainty” as children and young people move between foster or residential placements. CAMHS are unwilling to begin therapeutic treatment until they can ensure that a child will be based in the same location for a significant period of time.
18.Written evidence also commented on the budget cuts which CAMHS have faced over recent years. This reduction in funding has taken place across NHS and local authority budgets. In particular, many specialist teams which offered targeted support for looked-after children and young people have been abolished due to financial pressures. The Royal College of Psychiatrists wrote that although dedicated CAMHS for looked-after children had disappeared in some areas, because of pressures on local authority funding, in others they had survived because funding had been ring-fenced.
19.The extent to which local CAMHS should be wholly responsible for delivering services was challenged by Claire Bethel, Deputy Director for Children and Young People’s Mental Health and Well-being at DH. Ms Bethel told us “we need a multi-agency response, that if a looked-after child has a mental health problem it is not just a problem for CAMHS”. Wendy Lobatto, Service Manager at ‘First Step’ in Haringey, agreed with Ms Bethel and argued that CAMHS should not be seen as the only source of support:
The point I want to make [..] is that CAMHS should be all of our business and that emotional and mental health needs for looked-after children cannot, I think, be sequestered off into this agency called CAMHS, which then has to manage all of the difficulties, but that they should be the concern of all of us.
20.A ‘multi-agency’ response allows looked-after children with complex needs to receive specialist input across services and is advocated in The National Institute for Health and Care Excellence (NICE) guidance:
It is also reported that when multi-agency teams are supported and encouraged to address their way of working, they are better able to collaborate when handling difficult and complex situations, and more readily adopt a non-defensive approach that focuses on the best outcomes.
21.Looked-after children who need access to mental health services often have numerous and complex issues that require specialist input across multiple agencies. We have heard evidence that CAMHS is often unable to provide this care due to high thresholds and a refusal to see children or young people without a stable placement. The inflexibility of CAMHS is failing looked-after children in too many areas and leaving vulnerable young people without support.
22.CAMHS should not refuse to see children or young people without a stable placement or delay access to their services until a placement becomes permanent.
23.We recognise that CAMHS is not the only, or in many cases the most suitable, source of support for looked-after children. We recommend that where possible CAMHS should form a part of a multi-agency team in which education, health and social care work in partnership. Looked-after children and young people are best supported when professionals collaborate and services are tailored to the needs of the individual.
24.In addition to the challenges which looked-after children face in accessing CAMHS, several witnesses discussed the extent to which mental health services should prioritise those in the care system. Sarah Brennan, Chief Executive of YoungMinds and a member of the Government’s 2014 taskforce, recommended that all looked-after children should have a ‘fast track’ to and within CAMHS because of the increased risk of having experienced childhood neglect, abuse or trauma. Essex County Council told us that they had made looked-after children and young people a priority for accessing support in order to ensure that they received a specialist response as “swiftly and effectively as possible”.
25.Whether or not looked-after children and young people should have priority access to mental health services was a source of disagreement between the two Ministers in their oral evidence to us. Speaking for DH Alistair Burt told us that:
It is important to me that a looked-after child gets access to the service that they need through the system, but not necessarily simply because they are designated a looked-after child […] But it is important that the clinical mental health needs are assessed in the same way as they would be for any other child, and that a looked-after child has the opportunity to come into CAMH Services that are available to all.
26.In contrast Edward Timpson gave his opinion that looked-after children should be prioritised for services:
On this I am not prepared to break my own rule, irrespective of the fact that there is the clear clinical, constitutional position of the National Health Service that everyone has to access any health service based on clinical need. I think there are things we can do to ensure that children in care, and also children who move on to special guardianship order or on to adoption, have a much better arrangement in place to ensure that they do not lose out by there being insufficient resource for them.
27.It is important that all children who need access to CAMHS get it in a timely manner. In recognition of the distinct challenges which looked-after children and young people face, we recommend that they should have priority access to mental health assessments by specialist practitioners but that subsequent treatment should be based on clinical need.
17 Ofsted () para 4.11–12
19 NSPCC () para 7
20 National Children’s Bureau () para 3.3
21 National Children’s Bureau () para 3.5
26 See for further details.
30 The National Adoption & Fostering Service () para 13
31 Research in Practice () para 12
32 The Children’s Social Care Department of Portsmouth City Council () para 8
33 The Children’s Society and the Church of England () para 4.1
34 The Royal College of Psychiatrists () para 3.3
38 YoungMinds () para 13
39 Essex County Council () para 2.8
Prepared 27 April 2016