In 1995, following years of disjointed organisation and inequality in delivery, Together We Stand laid out a strategy to improve mental health services for children, young people and families. Adopting the strategy’s key principles transformed the York, Selby and Ealingwold CAMHS, as Barry Wright and Greg Richardson explain.
Twenty years ago, the organisation of mental health services for children, young people and families was disjointed, highly variable and reflected historical vagaries and enthusiasms more than good service planning or clinical needs.
Services had evolved from child guidance clinics run by local authorities2 and in-patient child and adolescent psychiatric units. Referral criteria therefore depended more on the work of the agency than the needs of the child and family, resulting in a range of referral thresholds, disrupted care pathways, highly variable waiting times and inequitable service provision.
In 1995 Together We Stand laid out a strategy for Children and Adolescent Mental Health Services (CAMHS) with the key principles of:
- Accessibility to overcome the inequity of provision and provide services nearer to the child and family.
- Multi-disciplinary approaches to ensure the discipline that was best suited to meet a child and family’s needs was available for them, and to ensure any CAMHS member would have those with a different range of skills and knowledge available to consult.
- Comprehensiveness to ensure a range of treatments and management strategies were geared to need rather than to the idiosyncratic skills of those employed in CAMHS.
- Integration of disciplines and tiers within CAMHS and with other agencies meeting children’s mental health needs, so that children and families were not continually being passed between different professionals and agencies. A focus on good inter-agency working centred around good care planning and the needs of the child and family.
- Accountability to ensure CAMHS were properly managed and took responsibility for the outcome of their work.
- Development and Change to ensure CAMHS took an active interest in what management strategies were effective and to structure their services to move with evidence based treatments and service developments.
The document recognised that everyone who has contact with a child in their development (e.g. parents, teachers, health visitors, social workers, paediatricians) has responsibility for their psychological and developmental wellbeing and therefore the vast majority of input to the psychological wellbeing of children occurs on an everyday basis and is not provided by CAMHS.
CAMHS have a role at the more serious end of mental health problems and have a valuable advisory role to all those working with children. Together We Stand laid out a tiered structure to clarify this and better deliver the care pathways.
Tiers of service
Tier 1: social, emotional and developmental support from professionals outside specialist CAMHS, as part of their everyday work, that generates resilience and prevents mental illness (e.g. teachers, social workers, special educational needs workers, pupil support assistants, health visitors, family centre workers, educational psychologists, school nurses, general practitioners, speech and language therapists, paediatricians, educational social workers, specialist teachers such as teachers of the deaf and home tutors, keyworkers, care coordinators in local authorities, physiotherapists, occupational therapists).
Primary Mental Health Workers (PMHW): are CAMHS professionals integral to CAMHS who provide support to Tier 1 and interface with specialist CAMHS. Locality based CAMHS workers are embedded in the communities they serve and relate to all the tier one workers in a geographical patch (e.g. each covering approximately 9,000 0-18-year olds).
Tier 2: any specialist CAMHS workers using their individual professional skills with children and families.
Tier 3: specialist CAMHS workers working in specialist therapeutic teams (e.g. eating disorders teams, looked after children’s teams, learning disability teams, family therapy teams)
[CAMHS workers work in both tier 2 and tier 3 and consult to tier 1).
This paper describes one CAMHS that has developed through the influence of Together We Stand. That experience is then discussed in the light of the various ways in which Together We Stand has been interpreted in different parts of the country, exploring the advantages and disadvantages of some of these interpretations in the light of the document’s original aspirations.
In the 1970s and ’80s CAMHS for York and the surrounding area of North Yorkshire (including Selby and Easingwold) was primarily based in a children’s in-patient unit and an adolescent in-patient unit, with a consultant psychiatrist and junior doctor support for each, a shared clinical psychologist, an occupational therapist, a social worker, two secretaries and the in-patient nursing staff.
There were productive links to the local education authority-run child guidance clinic. Referrals from general practitioners were generally for an in-patient bed, and community services were generally run from the child guidance clinic, which worked closely with psychiatric services. Family therapy was the treatment strategy of choice.
By the mid-1980s the need for community outreach was being recognised and the first community psychiatric nurses were appointed. By 1989 a specific building was designated for out-patient work, the children’s in-patient unit closed and a children’s day-unit was established on the same site as the adolescent in-patient unit and community services.
The existing CAMHS for York, Selby and Easingwold is a large (now 31 whole time equivalents) group of integrated professionals from many different disciplines working in tiers 2, 3 and 4 and supporting tier 1.
Primary mental health workers are each based in a designated geographical patch but regularly meet on the one site where all other disciplines are based.
Tier 1:to address the principle of accessibility the service now has eight primary mental health workers covering the total community served. They are all based in community settings such as children’s centres, family centres and other child focused multi-agency settings such as a shared building with the NSPCC.
Each primary mental health worker has a patch that typically involves two secondary schools and all its feeder primary schools, as well as the local primary care services. The primary mental health workers develop relationships with Tier 1 professionals working with children in their patch and are well known to them.
Primary mental health workers are the first point of contact for any discussion or new referral, about a child, from anyone in their patch. After discussion with the referrer and the family they mutually agree a course of action. This may involve:
- supporting the referring professional to carry out interventions for the family;
- co-working with the referring professional;
- provision of up to 4 sessions of work with the child, young person or family;
- Referral on to tier 2, 3 or 4.
The primary mental health workers are a skilled group with a range of generic mental health skills and are all child and adolescent mental health trained and so can deliver a range of interventions including systemic work, cognitive behaviour therapy, supportive psychotherapy, solution focused therapy and a range of other pragmatic approaches such as lifestyle advice, education or information, in line with the findings of Hickey and colleagues3.
The primary mental health workers provide mental health support to a wide range of professionals working with children and after consultation, take up referrals that they consider require specialist CAMHS input.
A mental health perspective is therefore more accessible to a far wider range of people in the community than could occur with formal referral systems into CAMHS. There is no waiting list. Primary mental health workers are therefore an informed conduit between tier 1 professionals such as teachers, paediatricians, social workers, and tiers 2, 3 and 4.
Referral up the care pathway
The primary mental health worker has the option at any time to make a referral to tier 2, 3 or 4. The receiving professionals will automatically take up the referral as it has been professionally triaged. The PMHW’s letter of referral will go to a weekly allocation meeting with the heads of all the disciplines within the CAMHS so that the latter’s staff most suited to the needs of the young person and family can be allocated to them.
Allocations are done fairly and equitably by careful monitoring of the numbers of new referrals to each clinician at tier 2 or tier 3 team based around the clinical time available and the needs of the child and family. Urgent referrals are facilitated by a daily duty clinician system, where a named, trained professional within specialist CAMHS leaves allocated time each day to see any urgent referrals from primary mental health workers or through the accident and emergency department or the self harm rota.
Tier 2: most clinicians in the service have tier 2 time available during their working week when they work individually with children and families, most of them also work in tier 3 teams, in order to give flexibility and job satisfaction. This leads to an integrated service, a CAMHS made up of many different disciplines including:
- Community mental health nurses
- Occupational therapists
- Child clinical psychologists
- Child and adolescent psychiatrists
- Speech and language therapists
- Family therapists
- Mental health children’s social workers
This ensures that there are multidisciplinary approaches and expertise available to young people and families.
Tier 3: the allocation system can also make referrals to tier 3 teams. Tier 3 teams are made up of individuals from the various professional groups within CAMHS. Some of the tier 3 teams also have professionals from other agencies involved with them depending on the needs of the tier 3 team. For example our local service has the following tier 3 teams:
- Family Therapy teams (locality based)4
- Looked After Children team5
- Learning Disability team6
- Autism Spectrum Disorders Forum7
- Attentional Problems team8
- Eating Disorders team9
- Paediatric Liaison team10
- Bereavement and Palliative care team11
- Parenting Risk Assessment team12 which ceased functioning in 2006 due to cost improvement staff cuts, prior to the publication of “Bearing Good Witness”13
As an example of multi-agency working, the autism spectrum forum, responsible for diagnosis, and intervention planning and co-ordination includes paediatricians, speech and language therapists, educational psychologists, pre-school teachers and children’s service workers alongside CAMHS professionals.
Various therapeutic models are employed across different teams including differing types of therapeutic modality (e.g. cognitive behaviour therapy, attachment work, systemic work), but also mode of delivery. For example group work occurs in a range of tier 3 teams, such as groups within the CAMHS team for parents of children with autism14 and multi-agency run groups with CAMHS involvement for bereavement within families15.
So the skills of individual professionals at tier 2 and the tier 3 teams ensures the principle of comprehensiveness, which is augmented by the local provision of the adolescent in-patient service.
Tier 4: there is an 11-bed in-patient unit on the site with a school with two part-time teachers provided by the local authority. As with other services, the in-patient team is integrated into generic CAMHS (for example with input into the community tier 3 eating disorders team), but also works closely with agencies outside CAMHS such as the early intervention services for psychosis and crisis home treatment and early intervention services based primarily in working age adult services.
There are also good links with professional tier 1 colleagues from the acute trust (e.g. paediatricians, physiotherapists, dietitians). At tier 4 there is also a National Deaf CAMHS that has its northern base in York and covers areas from Liverpool to Hull and Sheffield and to the borders16.
Strengths of the service
The main strength of the service is based on the principle of integration through the high level of communication between service members who tend to see each other on an almost daily basis. All referrals come in through one point of contact and therefore no children can be lost by boundaries around clinical sub-teams and referral thresholds.
Other benefits include the ease for inter-team referrals as well as the synergies and benefits accrued from co-location, joint training, secondments and weekly multi-disciplinary team meetings that involve tier 2 and 3 professionals and the primary mental health workers. The service has set up user and carer groups to ensure accountability to the people we serve and each tier 3 team has an operational policy as does the entire CAMHS so that the functioning of the service is transparent to our employers and commissioners.
Weaknesses of the service
Some of the weaknesses of the service relate to historical commissioning, particularly the high degree of financial difficulty that the host primary care trust has suffered over the last five years or so, resulting in low levels of investment unless dictated by national guidance.
Subsequently additional responsibilities have been given to CAMHS such as provision of services for 16–17 year olds out of school and additional services for learning-disabled young people with no new resourcing.
The service has taken the view, promulgated in the Children’s National Service Framework17, that as a CAMH service we should be able to provide for all children no matter what their background, so have never refused to provide a service for any young person, despite not being resourced to take on this extra workload.
Transition into adult services can also be more difficult as thresholds into adult mental health services can be high, for example using a threshold around IQ or diagnosis (e.g. no adult service for developmental disorders such as Asperger syndrome and attention deficit hyperactivity disorder, and a focus on severe and enduring mental illness).
Alternative arrangements in other parts of the country
Together We Stand has been adopted universally around the country but aspects of it have been interpreted in different ways.
In some parts of the country the choice and partnership approach (CAPA)18 has taken the primary mental health worker function and placed it in a more specialist setting of tiers 2 and 3. While this allows for good control of work flow, it has been interpreted in some parts of the country as a mechanism for putting boundaries around services (for example declining to see children who have behaviour problems or Asperger syndrome). This goes against the spirit of Together We Stand that has as a central vision universal and equitable services for all children and young people.
In other parts of the country the terms “tier 2” and “tier 3” have been altered from their original description, with for example the development of the term “tier 2 teams” defining the team by locality or perceived complexity of the work. This may lead to a team of people working individually without the opportunity to work with colleagues across “tiers”.
In some areas generic community CAMHS or specialist CAMHS are termed “tier 3 CAMHS”, which marginalises tier 2 work where core mental health work takes place A stand alone tier 3 CAMHS is not integrated or comprehensive and does not meet its tier 2 functions.
As a result, in some parts of the country tier 2 and tier 3 teams have separate bases with completely separate referral and allocation systems, working against an integrated service. These developments may serve to isolate professionals and create boundaries between services and tiers that were not intended in Together We Stand and may only reduce the accessibility of services for all children and young people.
All CAMHS staff should work in tier 2 for part of the time to hone and develop their professional assessment and management skills while working on their own. A system where tier 2 and tier 3 work are co-located and where professionals can work across both tier 2 (working individually with a child or family) and in tier 3 teams is likely to provide fewer barriers for children and families.
Another trend appears to be referring to PMHWs as “tier 2 workers”. Tier 2 is a function (a single professional working with a family) and so while some PMHWs will do short term tier 2 work, they are not, nor should they be, the only professionals providing tier 2 services, and they are not “tier two workers” as their main functions go far beyond this.
Tier 2 working is primarily a function of multidisciplinary CAMHS members. The main functions of the PMHWs should be consultation, support, information, signposting, networking and training. For a review of PMHWs seen from an educational perspective, see work from the National Foundation for Education Research 200919.
Locally the proper integration of multi-agency services between organisations has been aided considerably in York by a first class children’s service, without which mutually beneficial development would not have occurred.
This openness to development in the light of evidence about interventions and the structure of the CAMHS enshrines the sixth principle of development and change that is embraced by all agencies working with children and young people. This is a very different model from one that focuses only on the treatment of mental illness.
The challenges remain to ensure the psychological wellbeing of all children and young people as called for by the National CAMHS Review20. This means the pro-active identification of children whose psychological development is at risk, and ensuring commitment and societal support is provided for their families to bolster their wellbeing. It inherently supports any initiative that promotes the psychological well-being of children, either directly or indirectly.
Together We Stand has transformed our local service. In 1985 our service had 10 WTE staff plus in-patient nursing staff and took approximately 200 new referrals per year. We now have 31 full time and part time staff plus in-patient nursing staff and have close to 2,000 new referrals per year. In a catchment of 280,000 this greatly increased workload has been met with greatly increased efficiency.
In the early ’80s all referrals were initially assessed by a consultant psychiatrist, where now PMHWs see families first. The initial fears of general practitioners that primary mental health workers would prevent access to medical opinion has proved unfounded as response times have improved dramatically, much higher numbers of children access the service, seriously ill children are seen very quickly and appropriate care is much better directed by level of need.
There are now high levels of satisfaction and greatly improved accessibility to services. We currently have no waiting list for our service despite the fact that the service is funded well below reference costs (87 per cent) compared to CAMHS across the country. This is testament to the fact that children’s needs are directed rapidly to the most skilled and effective arm of the service that can meet those needs.
CAMHS also picks children up early because primary mental health workers are based in localities where they have close relationships with all professionals working with children and young people. Approximately 70 per cent of referrals from the youth offending team are already known to CAMHS and this compares to very significantly lower levels in other parts of the country, because the mechanisms, staffing and systems for getting involved early when problems arise, are not available.
We recognise that this is one locality (for example, not an inner city or predominately socially deprived locality) and that services vary for justifiable historical and local reasons, but we commend the flexibility of this system as a mechanism for creating structures around which healthy care pathways can thrive.
Clear and effective structure and organisation of services is essential to delivery, so the structures and guidance laid out in Together We Stand have yet to be superseded. As is often the case in the NHS they have been reinterpreted in some areas leading to the lack of clarity of CAMHS functioning that characterised the 1970s and ’80s. However the principles of service delivery described in Together We Stand promotes a clear guidance for a child centred service, integrated well into a multi-agency landscape, and it works exceptionally well when implemented effectively.
- NHS Health Advisory Service. Together We Stand. HM Stationery Office, 1995.
- Shepherd M, Oppenheim AN, Mitchell S. Childhood behaviour disorders and the child-guidance clinic: An epidemiological study. Journal of child psychiatry and psychology 1966; 7(1): 39-52.
- Hickey N, Kramer, T & Garrralda E. Primary Mental Health Workers (PMHWs) in Child and Adolescent Mental Health Services: A Survey of Organisation, Management and Role. Department of Health 2007
- Partridge I, Redmond C, Williams C, Black J, Richardson G. Evaluating family therapy in a child and adolescent mental health service. Psychiatric Bulletin 1999;23: 531-533.
- Gospel F, Johnson J, Partridge I. CAMHS and ‘Looked After Children’ (LAC). in Richardson G, Partridge I, Barrett J. (eds) Child and Adolescent Mental Health services: An Operational Handbook. RCPsych Publications 2010 (in press)
- Green K, Williams C, Wright B, Partridge, I. Developing a child and adolescent mental health service for children with learning disabilities. Psychiatric Bulletin 2001;25: 264-267.
- Williams C, Wright B. Services for autism spectrum conditions. in Richardson G, Partridge I, Barrett J. (eds) Child and Adolescent Mental Health services: An Operational Handbook. RCPsych Publications 2010 (in press)
- Bryan S, Wright B, Williams C. Attentional Problems Services. in Richardson, G., Partridge, I. & Barrett, J. (eds) Child and Adolescent Mental Health services: An Operational Handbook. RCPsych Publications, 2010 (in press)
- Roberts S, Foxton T, Partridge I, Richardson, G. Establishing a specialist eating disorders team. Psychiatric Bulletin 1998;22: 214-216.
- Black J, Wright B, Williams C, Smith R. Paediatric liaison service. Psychiatric Bulletin 1999; 23: 528-530.
- Wright B, Partridge I, Jones N. Bereavement services in Richardson G, Partridge I, Barrett J. (eds) Child and Adolescent Mental Health services: An Operational Handbook. RCPsych Publications 2010 (in press)
- Partridge I, Caswell G, Richardson G. Assessing the risks posed by parents. Child Psychology and Psychiatry Review 2001;6: 110-113.
- Donaldson, L. Bearing Good Witness. Department of Health, 2007.
- Pillay M, Alderson-Day B, Wright B, Williams C, Urwin B. Autism Spectrum Conditions Enhancing Nurture and Development (ASCEND): An evaluation of intervention support groups for parents. Clinical Child Psychology and Psychiatry, 2009 (2010 in press)
- Wright B, Elvans H, King P, Schneider J, Thompson R, Gillance H. Developing a multi-agency bereavement service. European Journal of Palliative Care 2002; 9(4): 160-163.
- Greco V, Beresford B, Sutherland H. Deaf Children and Young People’s Experiences of Using Mental Health Services. Children and Society 2008; 23: 455-469.
- Department of Health. The National Service Framework for Children and Young People’s Services, 2004.
- Kingsbury S, York, A. The 7 HELPFUL habits of effective CAMHS and the choice and partnership approach. A Workbook for CAMHS, 2ND Edition. reprinted 2008. Surrey: CAMHS Network. U.K, 2006.
- Atkinson M, Lamont E, Wright, B. NFER Voice on the role of Primary Mental Health Workers in Education, 2010 [online] www.nfer.ac.uk
- Children and Young People in Mind. The final report of the National CAMHS Review, 2008. Department of Health: Crown.