Dr Nick Waggett discusses the bottlenecks that cause difficulties in managing demand for children and young people’s mental health services and suggests some possible solutions
Along with many others, the Association of Child Psychotherapists has been concerned for some time about the quality of NHS child and adolescent mental health services in many areas. This is why we started the Treat Them Right campaign last year and undertook a major survey of NHS CAPts.
This led to the report Silent Catastrophe: Responding To The Danger Signs Of Children And Young People’s Mental Health Services In Trouble which found that whilst a lack of resources has been a major factor, an equally significant issue is the transformation and re-design of services in recent years.
These have led to inefficiencies that mean that resources, principally the skilled workforce, are not always used effectively and services can end up wasting resources on managing risk and high levels of re-referrals, rather than offering effective assessment and treatment.
These are contributing factors in care pathway fragmentation and the difficulties in managing demand for children and young people’s services.
The opposite of fragmentation is integration so we welcome the intention in the NHS long-term plan to deliver the “triple integration” of primary and specialist care, physical and mental health services, and health with social care.
Contributors to fragmentation
The development of “whole child care” should be at the heart of this integration. We should, however, recognise that many current forces and actions are pushing away from integration and towards fragmentation.
Our report identified what we called the Danger Signs of CAMHS in trouble. The ones that I would see as contributing to fragmentation are:
- Specialist services disappearing and being replaced by interventions that would previously have been offered in primary care/Tier 2;
- Thresholds increasing to manage demand, leaving children and young people to get worse before being seen, and an increasing mismatch between need and treatment offered;
- Assessment and treatment focused on symptoms, not the whole child or young person in context.
The outcomes of this can be seen in rising levels of suicide, self-referral to accident and emergency departments, and pressure on in-patient units.
There are then danger signs related to the workforce including:
- Profession-specific roles and disciplines dismantled and a loss of senior clinical leadership;
- Pressure on lower banded staff to perform specialist demands whilst skilled professionals are not working to maximum competency;
- Loss of multidisciplinary team working leaving services fragmented and staff isolated.
The outcomes of this can be seen in high staff turnover, poor morale and poor working conditions.
Effective children’s services
Those services that are effective and can be seen as models of excellence are ones that maintain effective multidisciplinary teams and do so because they see this as essential to working with the child and their family in an integrated way across health, social care and education boundaries.
To sustain this way of working requires staff trained in a range of complementary approaches, each with a sufficient depth of training to understand child development in its environmental context, who together are able to hold the whole child in mind and not fragment them into individual symptoms or presenting problems.
Narrowly defined care pathways or treatment models militate against this. A whole child approach requires effective team working in the context of managing the disturbance that seriously ill CYP can generate and this in turn needs robust leadership, both clinical and managerial.
Our report identified a number of Signs of Excellence in effective services and many of these can be seen as addressing the challenge of reducing care pathway fragmentation and managing demand for children and young people’s services. They include:
- Specialist services for children and young people from birth to age 25, supported by effective early intervention in the community;
- Skilled professionals able to work to their competency and support lower banded staff;
- In-depth assessment and formulation that considers the whole child or young person in context;
- Referral criteria that recognise the complexity of emotional, behavioural and social presentations of mental illness;
- Service models co-constructed with local agencies and service users and based on a realistic assessment of the burden of mental illness and sufficient funding;
- Strong multidisciplinary team working with effective leadership.
The ACP welcomes many aspects of the current transformation of services, and those signalled in the NHS long-term plan such as the development of MHSTs in schools and moves towards a greater focus on prevention and early intervention, but this must not be at the expense of specialist services and professions who are required both to treat those CYP with severe and complex needs and to support the new services and staff in their work.
Only in this way can we hope to achieve the triple integration in services for children, young people and families.