Mental health services

There is considerable variation in how Child and Adolescent Mental Health Services (CAMHS) are delivered across the UK, with impacts on waiting times and bed availability for children.

Background

  • Children and young people with mental health disorders require access to appropriate and timely services; ranging from community, inpatient to emergency services, depending on the severity of the child’s mental health.
  • Children and Young People’s Mental Health Services include a broad range of services which provide emotional or behavioural wellbeing support. Child and Adolescent Mental Health Services (CAMHS) provide specialist mental health assessment and therapy services. These vary between localities, with different admission thresholds and waiting times for treatment.

Key findings

  • Scotland had the highest rate of inpatient admissions for mental health problems in 2016/17 (61 per 100,000 children and young people), four times that of Wales (13 per 100,000). Admission to inpatient CAMHS facilities provides an indication of the amount of children severely affected by mental health problems.
  • The number of available inpatient CAMHS beds per 100,000 children and young people was lowest in Wales (3). England (11), Scotland (10) and Northern Ireland (9) had similar numbers.
  • Wales has the longest average length of inpatient stay at 99 days, compared to 72 in England, 52 in Northern Ireland and 50 in Scotland. The UK average length of stay in 2016/17 was 74 days; though there was considerable local variation, ranging from 10 days to 310 days between CAMHS organisations.1 Length of stay within inpatient wards may reflect patient factors (such as the severity of illness) or system factors (distance from patient’s home, capacity in inpatient services, adequacy of community-based care).
  • Caution should be drawn in interpreting how admissions, bed availability and length of stay impact upon the type of service provided to children and young people, without information on the types of admissions and discharges. However, it could be inferred from the data that Scotland CAMHS favour shorter admissions for children and young people with less severe symptoms, due to high rate of admissions and bed availability coupled with low length of stay. The inverse pattern in Wales may infer a higher severity threshold for admission, with less severe cases being managed within the community.
  • The number of children and young people seen by community CAMHS was highest in Scotland in 2016/17; though it is recognised that demand for community services across the UK is growing. It is concerning that CAMHS provision is comparatively lower in Wales for both inpatient and community settings.
  • Despite a reported increase in referrals in England from 2013/14 to 2017/18, median times from referral to assessment and treatment have both improved since 2012/13;2 although there is significant variation across the country. In Scotland, only 70.5% of children and young people received CAMHS treatment within 18 weeks,3 falling short of NHS Scotland’s standard of 90%.
  • Mental health workforce (consultant psychiatrists, community nurses and community psychologists) per population was similar across the UK nations in 2016/17, with the exception of Scotland being comparatively better served for all professions, particularly nurses and psychologists (36 and 21 per 100,000). Wales has the lowest number of psychiatrists and the second lowest number of community mental health nurses and psychologists (6 and 8 per 100,000), implying lack of capacity as a reason for its low activity rates among both inpatient and community based care. England had the lowest number of community CAMHS nurses, 16 per 100,000.

What does good look like?

Increased focus on outcomes data and experience of mental health services, rather than just data on mental healthcare activity. Children and young people have told us that waiting times for CAMHS represents a major barrier to accessing services.

Improved community based mental health services with a focus on early intervention. Community services enable children to be seen closer to home, without reaching severe or crisis points of ill health. A whole-systems approach to improving mental health would see the development of enhanced community services, which work in partnership with other agencies to provide the full pathway from early intervention to more intensive services based on specific needs. Integrated commissioning of these services will be an important enabler in improving mental health care for children and young people. We welcome initiatives that have focused on these approaches within the Together for Children and Young People4 programme in Wales and both the Transforming Children and Young People’s Mental Health Provision Green Paper5 and NHS England Long Term Plan.6

Policy recommendations

  • UK Government should resource Local Authorities to provide local pathways, agreed by multi-agencies, which improve access to support, resources and mental health services. These should be targeted at vulnerable groups – including, but not limited to: young men, Looked After Children, children and young people with long term conditions, and children not attending school.
  • There should be renewed investment, resourcing and ring-fenced funding of CAMHS services in England. Ringfenced funding provided should be reflective of local service demand and should be regularly reviewed. Funding for children and young people’s mental health services should grow faster than both overall NHS funding and total mental health spending.
  • UK Government should ensure Local Authorities have the resources to invest in a preventative, multi-agency approach to mental health across all ages (incorporating: education for children, young people and families; long term conditions; social determinants; and health promotion). The approach should focus on early intervention for children and young people, including minimising the need for admission and effective crisis services to ensure that children and young people can be effectively supported and their treatment managed in their communities as much as possible.
    • Mental Health Support Teams should be rolled out more quickly than outlined within the NHS England Long Term Plan, as currently only one quarter of children and young people will be covered by 2023/24. Additional funding is required for schools to allow them to employ school nurses, educational psychologists and/or counsellors that reflects the pupil body’s level of need.
    • We welcome NHS England’s Long Term Plan commitment to provide education based Mental Health Support Teams by 2023/4. This should be adequately resourced and introduced without delay.
  • We welcome the NHS Benchmarking Unit’s data collection on the performance of CAMHS services across the UK. All Trusts in England should report their data into the benchmarking data collection.
  • We welcome the Scottish Government’s commitment for an additional £28 million investment in CAMHS in the 2020-21 budget. This funding should be reflective of local service demand and regularly reviewed. Funding for children and young people’s mental health services should grow faster than both overall NHS funding and total mental health spending.
  • We welcome the NHS Benchmarking Unit’s data collection on the performance of CAMHS services across the UK. All Health Boards in Scotland should report their data into the benchmarking data collection.
  • The Together 4 Children and Young People programme and the Ministerial Group delivering the recommendations made in the Mind Over Matter’ (2018) report, provide structures to improve children and young people’s mental health services. We welcome continued funding for Together 4 Children and Young People which should continue beyond 2021. In particular, we welcome commitments to work with Regional Partnership Boards to understand current provision and enhance early help and support; and to implement the Neurodevelopmental (ND) pathway and standards developed during the first phase, working coherently to deliver ALN Act provisions and an enhanced response for children and young people with ND.
  • Welsh Government should resource and support these programmes to ensure delivery of a whole system approach and support the ‘missing middle’ who need services but do not meet the criteria for Child and Adolescent Mental Health Services (CAMHS)services. This system should incorporate education and a Whole School Approach, early intervention, community based support and targeted support for vulnerable groups.
  • We welcome the NHS Benchmarking Unit’s data collection on the performance of CAMHS services across the UK. All Health Boards should report their data into the benchmarking data collection.
  • HSC Trusts should improve integration and coherence of delivery of Stepped Care to ensure a less fragmented approach, as recommended by the Children’s Commissioner.
  • We welcome the Department of Health’s inter-departmental draft action plan (in response to Still Waiting), which committed to developing a regional governance structure for CAMHS services and creating a funding map of spending on CAMHS services. There should be delivery, adequate resourcing and ring-fenced funding of CAMHS services, which should be provided in a manner that is reflective of local service demand. Funding needs should be regularly reviewed and should grow faster than both overall NHS funding and total mental health spending.
  • We also welcome the Department of Health’s inter-departmental draft action plan, which committed the Department of Health, Department of Education, Public Health Agency and Education Authority to jointly publish an Emotional Health and Wellbeing Framework, covering prevention and early intervention. This should be published in 2020 and implemented.
  • We welcome the NHS Benchmarking Unit’s data collection on the performance of CAMHS services across the UK. All HSC Trusts should report their data into the benchmarking data collection.

What can health professionals do about this?

  • Early recognition and identification of need. Health professionals must be alert to signs and symptoms of mental as well physical ill health, in order to signpost or refer onto appropriate services for support or treatment in a timely manner. This includes being aware of the biopsychosocial model of disease, and a recognition that psychological problems often manifest with physical symptoms.
  • Improved mental health training for health professionals. Mental health should be a core part of the training curriculum for all health professionals who deal with children and young people. One useful resource is the e-learning provided through the Mind-Ed resource which help professionals identify and help children and young people with mental health issues. There are modules designed for families too, to which professionals may wish to signpost carers.
  • Advocate for the mental health of local children and young people. Use available data on mental health prevalence and service capacity to articulate the needs of your local population, to advocate for adequate provision of mental health services to local decision makers, from NHS commissioners, to social care, education and local government.
  • Encourage integrated working between organisations and agencies across the whole children’s workforce. Integration of practice, education, pathways and commissioning will ensure that prevention, recognition, early intervention, support and onward referral is commonly addressed by professionals.

Doctors need to remember that sometimes children’s hearts are broken.

Young person speaking to RCPCH &Us

Contributing authors

  • Dr Ronny Cheung, RCPCH State of Child Health Clinical Lead
  • Rachael McKeown, RCPCH State of Child Health Project Manager
  • Dr Rakhee Shah, RCPCH State of Child Health Clinical Advisor

Royal College of Paediatrics and Child Health (2020) State of Child Health. London: RCPCH. [Available at: stateofchildhealth.rcpch.ac.uk]

References

(2)

Crenna-Jennings, W. & Hutchinson, J. 2018. Access to children and young people’s mental health services – 2018. Education Policy Institute.

(6)

NHS England (2019) The NHS Long Term Plan.