In 1996, our child and adolescent mental health team had become overwhelmed by the growing number of cases on our waiting list.

Although each new case would be discussed in detail, and accorded a priority rating, it had become impossible to make just comparisons of relative need and urgency.

We discussed contacting all those waiting more than six months, which we were ethically bound to do, but there was great anxiety that this would stimulate hope or despair.

The resolution was a letter inviting them to contact us and stamped envelopes to increase the likelihood of a response. This was superseded by one which made it explicit that failure to reply would result in our closing the case or referral.

We received replies from half the clients contacted, 36 in all, half of whom were quite willing to continue on the waiting list, much to our surprise.

An almost identical number chose to be removed from the list or told us that the situation had worsened. Only one chose to re-contact the referrer, and two had moved. Where the situation had deteriorated we were able to reprioritise and offer appointments.

The cases of those who did not reply and some of those who did could be closed. The former entailed first confirming with the referrer, lest there be problems with literacy or language. Cases of those who had left the district could be closed. Team meetings became less burdensome - an unanticipated benefit.

Towards the end of the financial year, some underspend was available to employ a short-term counsellor to offer a brief but largely effective service to those who had elected to stay on the list.

This work was done only in one team in a larger, beleaguered service. The service is now proposing to separate more formally the activities of assessment and treatment.

Over the past two years we have also looked at referral quality. I imagine the high variability we found is common. This unreliability of information makes prioritisation, risk and needs assessment more difficult.

Principal child psychotherapist

Newham Community Health Services trust