Where information about individual providers’ thresholds for accepting referrals or waitingtimes are included in this report, it is important to highlight that a straightforward comparison between different providers is difficult. There are no standardised eligibility criteria across CAMHS and each provider collects data about access and waitingtimes in a different way. Providers with the highest percentage of children who are not accepted may not be the worst performers, as other providers may be measuring this in a different way. Similarly, it is difficult to compare performance across providers on maximum waitingtimes because of the risk that these are outliers. We have included the average of these maximum waitingtimes to demonstrate that there are many youngpeoplewaiting a lot longer than the median waitingtimes demonstrate. A similar methodology has been employed by NHS Benchmarking. 5 The wide variation between providers indicates that much more
Timely and high-quality specialist care will always be necessary and more needs to be done in order to ensure it is in place across the country. This must include a concerted strategy to build up the workforce to meet current demand, high-quality joined-up working in all areas, ensuring that committed funding reaches frontline providers, and the introduction of national compulsory data reporting on key access and outcome measures. The government should look again at the FOI exemption applied to private providers when they are providing a publicly funded service. Stable and consistent definitions of who is eligible for treatment and time to both assessment and treatment must accompany the introduction of accountability measures to avoid ‘gaming.’
healthservices. The Department believes that the ambitions set out in the Forward View and the Green Paper will help deliver a step-change in improvement in support to children and youngpeople. The latter introduces a new approach in schools, including the creation of new mentalhealth support teams. However, the balance between pace, funding and need to test approaches means that the Green Paper will only be rolled out to 20–25% of the country by 2023 (paragraphs 1.10, 1.12, 1.16 and 2.23, and Figure 4). 7 The government has not set out and costed what it must do to achieve Future in Mind in full. Future in Mind identified 49 proposals on themes such as resilience and early intervention, access and workforce development. However, the current programmes to take this forward will not deliver its proposals in full. Our analysis highlighted that the programmes do not have explicit objectives for some proposals, particularly those related to vulnerable groups. The government has not yet identified what actions and budget it will need to implement each proposal in Future in Mind, what progress it has made so far, and what further work is required to deliver it in full (paragraphs 1.11 to 1.13 and 2.2, Figures 4 and 5).
But, too often, children and young people’s emotional wellbeing and mentalhealth is not given the attention it needs. Far too many families have experienced poor children’s and adolescent mentalhealth care. This isn’t endemic, and we have made great progress in the last few years, but it remains unacceptable that not every child or young person gets the help they need when and where they need it. Some don’t get any care at all, and their problems escalate to a crisis point. This isn’t due to lack of good will – there are many highly skilled and highly valued staff working with children and youngpeople who want to make a real and lasting difference to their lives but there are barriers in the system itself which prevent change. I have been changing that system. Since 2011, my Department and NHS England have invested over £60 million in the Children and Young People’s Improving Access to Psychological Therapies programme. We have funded the development of MindEd – giving more advice to health professionals about how to help youngpeople with mental ill-health. We have put more mentalhealth beds for youngpeople in the system, as well as training new case workers to offer help where it is needed. But this isn’t enough – we need to be ambitious if we want children and youngpeople to live happy, healthy lives. This is why I set up the Children and Young People’s MentalHealth and Wellbeing Taskforce. I wanted to identify what the problems were, what was stopping us
A range of mentalhealthservices, in the community or in an outpatient setting, have been developed to manage youngpeople with serious mentalhealth problems who are at high risk of being admitted to an inpatient unit (DOH 2004; NSF 2004). These alternative services may prevent youngpeople from developing a dependency on the hospital environment or from being stig- matised. In addition, they may facilitate the transfer of any ther- apeutic gains to the young person’s everyday environment, thus maximising the potential for sustaining improved health outcomes (Katz 2004) and for educational attainments to be less severely af- fected (Milin 2000). Examples include early intervention services in the community for youngpeople with first episode psychosis (McGorry 2002), assertive outreach (McGorry 2002), dialectical behaviour therapy (Miller 2002), family therapy (Lock 2005) and multi-family therapy for anorexia nervosa (Scholz 2001). The way services are organised also differs. Service configurations include the provision of multi-agency integrated home care (DOH 2004), therapeutic units based in a day unit, or multi-agency services providing intensive specialist outpatient therapy for youngpeople with severe mentalhealth problems (Street 2003).
resilience) and life skills and effective coping mechanisms when dealing with bereavement, grief and relationship loss. The important role of family and school in supporting attainment of life skills was identified along with recommendations for online information on mentalhealth and wellbeing and suggestions to improve quality of and access to healthservices. The literature review highlights the need for bisexual specific youth research and health promotion resources, as well as more inclusive organisational policies, programs and practices to address issues of being ‘invisible’ for youngpeople who identify as lesbian, gay, bisexual, transgender and intersexual (LGBTI). In addition, the inadequate representation for youngpeople identifying as bisexual was shown to contribute to a range of mental, social and sexual health concerns and further marginalisation from healthservices. In conclusion, a positive and holistic concept of health requires a model of health practice that addresses both the impacts and determinants of health problems. The review considers an extensive body of theoretical and evidence-based literature that confirms the need for a paradigm shift in how we conceptualise adolescent health and wellbeing. Several writers at a global level posit the need to draw together recent developments in biology and
As a result of a major review of all Australian mentalhealthservices completed in 2014 , the mentalhealth system is undergoing major reform. The key finding of this review was that Australia’s mentalhealth system is poorly planned and integrated resulting in less than optimal wellbeing and participation, therefore hinder- ing productivity and economic growth. Consequently, recommendations emerged to improve mentalhealth system sustainability based on three key principles: person-centred design in which services are organised around the needs of people, a new system architecture based on a stepped care framework that provides services of varying intensity to match people’s level of need, and shifting funding to more efficient and effective ‘upstream’ services and supports (i.e. population health, preven- tion, early intervention, recovery and participation) . To this end, from July 2016, Primary Health Networks became the commissioners of primary care psycho- logical treatment (including both ATAPS and headspace amongst other programs) within a stepped care approach according to local population mentalhealth needs .
Although having provision too close to home or a young person’s local area may be a problem for some, a more widespread concern - and a serious problem for young refugees lacking knowledge of their local area and transport system - is the lack of local services in some parts of the country. This, as well as not being able to self-refer and get help promptly, was raised in several of the focus groups as a real stumbling block to accessing provision. This finding is given further weight when the results of the study mapping are considered, namely that the distribution of services that are either targeted on Black and minority ethnic groups, or who have developed strategies for improving access, is very patchy across England and Wales. There was much support for drop-in types of provision - and for much greater flexibility over opening times and the use of different venues, the latter being linked to worries about stigma and confidentiality and also a view noted by some of the respondents that hospital based provision is ‘daunting’.
surveyed felt that the Internet had helped a little or a lot with a mentalhealth, alcohol, or other substance use problem, and that 85% of youngpeople surveyed would recommend it to a friend or family member. In addition, 94% felt somewhat satisfied or very satisfied with the information provided online. The study illustrated that a general Internet search served as the primary gateway to access information about mentalhealth and well-being, but once this initial search phase was complete, peer support groups and forums proved less popular than mentalhealth and generalist websites. The survey respondents were less in favor of online journals, reading other people’s stories, or accessing fact sheets, but general information and question-and-answer forums were popular. 24 The paper argued that youngpeople are using
Overall, more than two thirds of 5 to 19 year olds who accessed professional services for a mentalhealth reason reported waiting less than ten weeks to see the specialist. This ranged from 65.2% of those who had contact with a physical health specialist, to 93.0% of those who had contacted teachers about mentalhealth.
This section of the interview is about the child’s level of activity and concentration over the last 6 months. Nearly all youngpeople are overactive or lose concentration at times, but what we would like to know is how the child compares with other youngpeople of their own age. We are interested in how they are usually – not on the occasional 'off day'.
At a national level, the pilot programme very much demonstrates the potential added value of providing schools and NHS CAMHS with opportunities to engage in joint planning and training activities, improving the clarity of local pathways to specialist mentalhealth support, and establishing named points of contact in schools and NHS CAMHS. At the same time, the evaluation has underlined the lack of available resources to deliver this offer universally across all schools at this stage within many of the pilot areas. Given the pilots show that additional resources would need to be allocated locally to deliver the offer universally across all schools, further work is needed to understand how sustainable delivery models can be developed. 62
in four students (24 per cent) did not attend school, college or university because they were concerned what other students would say and 15 per cent of people experienced bullying as a result of mentalhealth problems. It also found that nearly a third (31 per cent) of those had been subject to discriminatory language, including being called “crazy” and “attention seeking”. Nearly half of respondents (48 per cent) chose not to tell people about their mentalhealth problems, instead saying they were absent due to physical illness. In response to the findings, the then Minster for Care Services, Norman Lamb, said:
The Integrated Comprehensive CAMHS Pathway is made up of a range of MH services in Liverpool, including NHS CAMHS and voluntary services, as well as other specialist services. These services form an inter-linking pathway that can be accessed at any stage, dependant on the user’s MH needs. A single point of access can handle both self-referrals and referrals from a professional, to assist CYP in finding the most suitable service along the pathway. This approach has led to reduced referrals to more specialist services, and improved patient outcomes and satisfaction. 28,37
The aforementioned consultations (MHF, 2004; MHF, 2007a) highlight young people’s desire for a change to systems of mentalhealth support. They reveal an awareness of the limitations of current approaches, implicitly critiquing or even rejecting the medical model. This is reinforced by young people’s continued reluctance to accessservices (Brophy, 2006). It also suggests that they have a very clear sense of the models of support that will work for them. This research echoes these earlier consultations and youngpeople stressed that they want person centred services that are commissioned across the age range – ie. 16 – 24yrs,and importantly see them as ‘individuals and not a collection of symptoms’ (MHF, 2007a: 26). In instances where youngpeople do want access to psychological therapies and emotional support, they prefer this to be delivered through community based services that are informal, flexible, accessible, confidential and non- stigmatising. They talk about opportunities to build friendships and gain support from peers who have had similar experiences and they stress the importance of fun and creative group activities. They also emphasise the value of building trusting long term relationships with non-judgemental and accepting workers who support them with care and empathy (Brophy, 2006; MHF, 2007a; Joy et al, 2008):
In March 2015, the Department for Education announced an investment of £25 million for voluntary and community sector grants for organisations that work with vulnerable children and youngpeople. For the first time, mentalhealth was identified as a separate theme within the grants, and organisations specialising in child mentalhealth care were awarded £4.9 million. This includes £394,067 for Mind to develop a pilot promoting positive mentalhealth and wellbeing in schools, and £439,657 for the Anna Freud Centre to create a comprehensive directory of all mentalhealthservices to provide an authoritative source of mentalhealth information for schools. 40
The cost of the status quo as it pertains to the mentalhealth of youngpeople is high. The burdens borne by the individuals directly affected by poor mentalhealth, and their families and friends, are essentially incalculable. From a policy-making perspective, however, it is often useful to quantify total economic costs, including social costs. Competing interests vie for limited funds, and one way to prioritize spending is to estimate the price of leaving the current system as it is—―business-as-usual.‖ When estimating the burdens that are associated with various injuries, illnesses, and risk factors, the two most common metrics are direct costs, and healthy years of life (a measure that reflects both premature death, and years lived with a disability). To count direct and indirect costs, we need to consider both what society currently spends on mentalhealth treatment and prevention, and what it spends now, and in the future, due to the inadequacy of these efforts. To illustrate, when a child’s mentalhealth challenges are not properly addressed, costs include not only those associated with unsuccessful attempts at treatment, but also may encompass expenses for special education services, and a parent’s lost productivity due to the child’s greater need for care.
encompasses anyone working in universal children’s services (including teachers and school nurses); Tier 2 workers are the unidisciplinary specialists (such as psychologists) working in primary and community-oriented care; Tier 3 services are provided mainly by multidisciplinary teams working in outpatient (sometimes day care) services; Tier 4 provision – which equates largely with hospitalisation – is for the minority with the most complex needs (CAMHS Review, 2008). Primary-oriented care and community-oriented care are thus an inherent part of CAMHS, yet this provision is often overlooked. For many, CAMHS is synonymous with Tiers 3 and 4 or, at the very least, it begins at Tier 2. These higher tier services are often overstretched, with many having long waiting lists (Clarke et al. 2003, Etheridge 2004, CAMHS Review 2008). Moreover, in-patient (Tier 4) services are expensive, both for the service provider and for the families receiving the service (Jacobs et al. 2004).
demand on beds and provide care closer to young people's homes and communities. As the process of transforming child and adolescent mentalhealthservices continues, data on the consistent provision of these services should be collected and monitored at a national level. In addition, further training is needed for staff outside of specialist CAMHS, such as GPs, ambulance and A&E staff and the police who are likely to be first respondents to youngpeople in crisis. New models of supporting youngpeople in crisis such as street triage and crisis cafes should be replicated across the country.
Recognition that a child has poor mentalhealth, by the parent, young person or other key adults, is an essential step in accessing support (Gronholm et al., 2015). Children with poor mentalhealth may be supported by a number of different services. Primary health care and school staff provide front line mentalhealthservices, while CAMHS, paediatrics, educational specialists (such as educational psychologists or Behavioural Support Teachers) and social care workers comprise the common publicly provided specialist services. Children and youngpeople may also gain informal support from family, friends, the internet / social media and self-help organisations, or from third sector or private organisations. The previous child mentalhealth surveys in the series found that access to informal support was very common. Access to private forms of professional services and practitioners was extremely rare (Ford et al., 2005; Green et al., 2005).