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CHAPTER THIRTEEN: MENTAL HEALTH SERVICES FOR CHILDREN AND YOUNG PEOPLE

The Action Framework listed one key target and 10 milestones along with 8 actions on mental health.

13.1 TARGETS AND MILESTONES

Key target

Consultees were asked whether they agreed with the key target to reduce the suicide rate between 2002 to 2013 by 20% and, as seen in table 13.1 below, over three-quarters (78%) of those responding to this question agreed.

Table 13.1
18: Reduce suicide rate between 2002 to 2013 by 20%

Base: All those responding in each category

Consultees also offered a number of comments regarding the target. Thirteen suggested that alternative, more positive measures should be used rather than only monitoring the reduction in suicide rates.

An NHS Management & Strategy Group stated "We would like to see other indicators of mental health developed other than suicide. Eating disorders and self harm are not reflected. There needs to be greater emphasis on the promotion of positive mental health and the inclusion of indicators for risk factors for poor mental health and protective factors for positive mental health would be useful".

Two consultees mentioned some doubts as to the relevance of using the suicide rate due to very low rates being reported and additionally 2 consultees queried whether the rates for children and young people should even be combined.

There were also some concerns that the suicide rate will be the only national target pertaining to mental health among children and young people. Twelve consultees suggested that this would not reflect the range or nature of mental health problems and disorders (inclusive of severe and enduring mental illness, personality disorders, self harm, risk seeking behaviours etc) experienced by younger people. A Professional Body stated "Focusing on the suicide rate as the main indicator of mental health of a population is too narrow. Other measures need to be included, for example school exclusions, being received into care, accessing MH support, psychological reasons for consulting with GPs, etc."

It has been suggested that other indicators should be used either in conjunction with, or as an alternative to, the suicide rate.

Amongst non-suicide mental health targets proposed, 8 consultees suggested that self harm should be used as an indicator; one Local Authority commented "the existing Health Target is fine but there is no focus on self-harm which is a far bigger problem". In addition, eating disorders were suggested by 3 consultees.

Other suggested alternative measures include:

• social and health adversity e.g. school exclusion, received into care etc (3 mentions);
• well being (2 mentions);
• self confidence/ self esteem (1 mention).

Milestones

Consultees were then asked whether they agreed with the 10 milestones listed in the Action Framework. In each case a large majority of those responding at each question expressed agreement.

Integrated Children's Services Plans to include clear actions, milestones and resources for implementation of the Framework for Promotion, Prevention and Care by 2006

Table 13.2
19: Integrated Children's Services Plans should include clear actions, milestones and resources for implementation of the Framework for Promotion, Prevention and Care by 2006

Base: All those responding in each category

Three consultees expressed concern that these targets might not be achievable by 2006. Three other consultees also expressed concern that there might not be sufficient resources, capacity or time to achieve these targets by 2006. One Professional Body stated "Unless permanent ring-fenced resources are made available to implement the framework, delivered through health planning mechanisms such as CHPs, it is hard to see how many of these targets will be achieved." One Local Authority stated "Resources for mental health provision often falls short of what is required - this needs to be addressed to ensure improvements in this area. Does the date need to be postponed?"

Two consultees acknowledged the need for an integrated multi agency approach to take forward the Framework for Promotion, Prevention and Care by 2006.

Incorporation of NHS Board and Regional Workforce Plans to include specific workforce planning for CAMHS by 2007

Four consultees expressed some concern over the time set and resources required in order to achieve inclusion of CAMHS specific workforce planning within the NHS Board and Regional Workforce Plans. One NHS Clinical Group stated "Workforce planning targets are unrealistic in their opinion in terms of the financial commitment required. The local provision of in-patient CAMS beds in our area is important and is currently done well. Any change needs to be better than what is currently in place."

Table 13.3
20: NHS Board and Regional Workforce Plans incorporate specific workforce planning for CAMHS by 2007

Base: All those responding in each category

Ensuring that a named mental health link person is available to all schools by 2008

Eight consultees chose to comment upon this milestone with most welcoming the move to establish a mental health link person available to all schools. Two consultees queried the level of availability of each named mental health link person to schools in terms of how many schools per worker would be allocated and whether all schools would be covered.

Three consultees requested further information on what the remit of each mental health link person would be in terms of whether they would be working directly with pupils providing health promotion / illness prevention measures or a mixture of all these aspects. As noted by an NHS Service Provider, "How many schools per worker will be allocated? Currently in some areas there are very high numbers of pupils with emotional and mental health issues which are bordering on clinical illness. We are also interested to know what will be the remit of the mental health link worker i.e. will it be working with these pupils in school or will their role be health promotion / illness prevention or a mixture of all aspects?"

Three consultees also asked who would be approached to fulfil the role as a mental health link person. Suggested professions that might be approached included school health nurses, health workers, social workers and teachers.

One Local Authority expressed concern that the timescale was too optimistic.

One Individual (Professional) was concerned that special schools should be included within the remit of a named mental health link person.

One Local Authority also suggested that training would be required for all new staff above and beyond 2008 in order to mitigate the effects of staff turnover.

Table 13.4
21: A named mental health link person is available to all schools by 2008

Base: All those responding in each category

Ensuring that basic mental health training is provided for, and accessed by, all those working with, or caring for, looked after and accommodated children and young people by 2008

This milestone attracted responses from 14 consultees covering a wide range of queries.

Three consultees requested further information on what 'basic' mental health training referred to e.g. nationally defined or accredited training and not designed to be a replacement for specialist fully trained staff. A Public Body stated "We recognise the higher incidence of mental health problems in looked after and accommodated children. It would be helpful to clarify what this proposal means e.g. what level of training is proposed and what does 'basic' mean in this context? Is it aimed at all staff working in these settings?"

Two consultees queried whether it was over ambitious (in terms of resources) to provide basic mental health training to all staff working with children and young people.

A further two consultees suggested that the milestone be amended to include all people working with children and young people, and not just those working with vulnerable people.

One Individual (Professional) asked whether special groups would be catered for e.g. children with eating disorders. Another Individual (Professional) requested further information as to whether the action would include specific professionals e.g. community paediatrics.

One Local Authority cited a concern that this target is overly clinically focussed. They suggested that there is the potential for over diagnosis of mental health problems / treatment with medication rather than reliance upon less clinical forms of treatment.

One NHS Board queried whether there would be enough time to train all teachers by 2008, while another NHS Service Provider suggested that training should be regularly updated i.e. provide refresher courses.

A charity / volunteer organisation also suggested that training should be provided to those who are working with young carers. Another Charity/ Volunteer Organisation also queried how the training would be financed.

Table 13.5
22: Basic mental health training is provided for, and accessed by, all those working with, or caring for, looked after and accommodated children and young people by 2008

Base: All those responding in each category

Ensuring 65% of NHS Specialist CAMHS staff in every NHS Board area have accessed advanced professional training by 2008 increasing to 80% by 2010

Four consultees queried the nature of the training and requested further information on the nature of the training in terms of how specialist the training will be and whether it will include variations appropriate to professional groups and the skills mix of teams.

One NHS Clinical Group stated "Greater clarification is required surrounding the advanced professional training available for CAMHS practitioners. The mental health needs of looked after and accommodated children have not been fully addressed and met to date, and any move to improve this is welcomed. As a first step mental health first aid training would be useful. An increase in CAMHS staff establishment is urgently required, as this will be key to delivering change CAMHS to double in size over next 10 years."

Table 13.6
23: 65% of NHS Specialist CAMHS staff in every NHS Board area have accessed advanced professional training by 2008 increasing to 80% by 2010

Base: All those responding in each category

To ensure that across Scotland, 47 inpatient places are available in dedicated psychiatric units for young people aged 12-18 increasing to 56 by 2010

Eleven consultees commented upon this milestone, with a majority in agreement. However, 4 consultees queried the measure.

Three consultees requested further information on the allocated places in terms of eligibility, whether younger age groups might be introduced and if the number of places might increase over time.

Other single comments from consultees included:

• One Education Body commented that "there is currently inadequate provision of child psychiatry in the region. There is a need for more even coverage of this service for children and young people";
• A Local Authority mentioned that 2010 appears to be some time away for such important issues to be brought about;
• Another Local Authority suggested that there did not appear to be many places allocated for psychiatric units;
• An NHS Board stated that this action "will require significant resources to achieve its objectives. Plans will need to be linked to proposals to develop a national young people's forensic in-patient resource";
• An NHS Management & Strategy Group suggested that access should be widespread and not just limited to the central belt of Scotland.

Table 13.7
24: Across Scotland, 47 inpatient places are available in dedicated psychiatric units for young people aged 12-18 increasing to 56 by 2010

Base: All those responding in each category

Clear and agreed local procedures are put in place to identify and support those children and young people in need of additional or specific support for their mental health by 2010

Eight consultees expressed opinions on this target.

Three consultees felt that the target was too vague in that the action point required a clearer definition of which groups should be involved, while providing guidelines on how to prioritise, and the extent of what is being proposed. A Public Body stated "We support the principle of locally agreed procedures but would welcome clarity about the extent of what is being proposed e.g. specialist MHOs for children and young people / greater links with CAMHS staff".

Two consultees stated that there was a need for a full range of support services to be available to children, young people and their families. These services should include psychology, social, education and health work and would require multidisciplinary planning within Local Authorities. A Local Authority stated "It is important that social work, education and health work together at the level of frontline services and not only at strategic planning levels. Frontline, targeted training should focus on joint assessment teams - the multidisciplinary planning forums within authorities".

Other single comments included the need for the inclusion of a target for improving mental health provision for children and young people in local delivery plans (Voluntary/ Charity Body). A further comment by a Local Authority was that 2010 appears to be quite a distant target date considering the importance of the issue.

Table 13.8
25: There are clear and agreed local procedures in place to identify and support those children and young people in need of additional or specific support for their mental health by 2010

Base: All those responding in each category

New CAMHS staff complete the "New to CAMHS" training within a year of taking up post by 2010

One single comment was made by a Professional Body that "These courses are not appropriate for all professional groups, for example, clinical psychology training will have covered the topics already. Targets need to be about accessing the training appropriate to the professional group and skills mix of a team".

Table 13.9
26: New CAMHS staff complete the "New to CAMHS" training within a year of taking up post by 2010

Base: All those responding in each category

There should be an annual increase in primary mental health work until 2015, by which time it should account for 25% of NHS specialist CAMHS activity in every NHS Board

Five consultees commented on the need for a clear definition of 'primary' mental health work and guidelines on how to achieve increased specialist CAMHS activity.

One Individual (Professional) stated "The milestone for annual increase in primary healthcare work by NHS specialist CAMHS is confusing. 'Primary' is by definition not specialist and thus not provided by specialist staff. Does this mean that specialist CAMHS staff will deliver 25% of their activity in primary and community settings? We would also welcome targets for primary care capacity building in addition to activity".

Table 13.10
27: There is an annual increase in primary mental health work until 2015, by which time it should account for 25% of NHS specialist CAMHS activity in every NHS Board area

Base: All those responding in each category

There is an annual increase in NHS specialist CAMHS workforce capacity until 2015, by which time it should reflect the skill mix and staffing profiles outlined in Getting the Right Workforce, Getting the Workforce Right

Four consultees made individual comments on this target.

An Individual respondent commented on the importance of not separating CAMHS as the focus of workforce development plans to the detriment of other services.

One Individual (Professional) stated "All specialist staff should have access to specialist training. The milestone for clear and agreed local procedures in place to identify and support these children and young people in need of additional or specific support for their mental health by 2010 seems some time away for one of the most important issues in the section."

An NHS Management & Strategy Group stated that "we understand that this is not a policy document but guidance. Workforce needs should reflect the model of care - this may mean investment in the community. This section makes no reference to the needs of children to access mental health care in remote and rural settings, in particular island settings. In these settings children and young people are often managed in adult settings without appropriate decision support. A measure to state that services will be planned to ensure that clinicians in remote settings have 24-hour access to specialist clinical decision support should be added".

An NHS Service Provider suggested the need for larger scale development of joint working with CAMHS across agencies.

Table 13.11
28: There is an annual increase in NHS specialist CAMHS workforce capacity until 2015, by which time it should reflect the skill mix and staffing profiles outlined in Getting the Right Workforce, Getting the Workforce Right

Base: All those responding in each category

Other general comments on milestones

A number of more general comments were made regarding mental health services for children and young people.

Eight consultees suggested a wider remit in mental health related services for children and young people at risk, encompassing: learning difficulties, challenging behaviour, self harmers, eating disorders, school refusers and those with disabilities.

Six consultees stated that there needs to be adequate resources or funding made available for the CAMHS framework in order to achieve the targets set out.

Four consultees expressed the opinion that there were not enough training places or candidates in training in order to meet staff levels needed to achieve the milestone targets.

Three consultees recommended that adequate resources need to be allocated locally rather than at a national level.

Two consultees suggested that a multi-agency approach requires mainstream services to develop more capacity for mental health issues including mental health promotion, identification of problems, planning and training.

13.2 ACTIONS

The Action Framework listed 8 actions in relation to mental health services for children and young people and invited consultees to comment. Responses from 27 consultees were mainly general in nature but some made points in relation to specific actions.

Completion by all NHS Boards and their partners of a self-assessment of their provision against the Framework for Promotion Prevention and Care

One Local Authority stated they have jointly agreed protocols for assessment and identification of children on the autistic spectrum. In addition, they held a very successful stakeholders event late last year, which proved an excellent multi-agency opportunity to share developments.

An NHS Service Provider stated that the timescales are not achievable given the under-resourcing and reorganisation of many mental health teams.

NHS Boards and their partners to develop an integrated plan for implementation of the Framework for Promotion Prevention and Care, with agreed milestones and priorities, including action to ensure the involvement of children and young people

A variety of comments were made for this action, with 10 consultees generally welcoming the suggested action point. Three consultees wanted to see more advice provided on practical procedures and service delivery issues and 2 suggested the need for earlier identification of mental health issues and support, particularly for more 'hard to reach' children and young people.

Two consultees stated that the suggested timescales were unrealistic given the issues of under-resourcing and reorganisation of many health teams.

One Individual (Professional) stated that the involvement of young people is vital and needs to be expanded although it can be a difficult process.

A Local Authority indicated that children's services has gone some way to implementing the priorities in the Framework. Another Local Authority suggested that the long term nature of this work requires care funding and sustainable services.

Workforce planning to address issues raised in Getting the Right Workforce, Getting the Workforce Right, to build the necessary capacity for implementation of the Framework for Promotion Prevention and Care

An NHS Service Provider stated that the timescales are not achievable given the under-resourcing and reorganisation of many mental health terms.

A Public Body agreed that this set of actions should help address current service delivery issues within the Children's Hearings System.

All NHS Boards and their partners to monitor progress and review their action plan for implementing the Framework for Promotion Prevention and Care on an annual basis

No comments were submitted regarding this particular action.

All NHS Specialist CAMHS to have a strategic training plan, linked to CAMH service planning and reflecting the advice in Getting the Right Workforce, Getting the Workforce Right

An Education Body queried the action by asking whether staff working with groups of children and young people who are very vulnerable would not require more than basic mental health training. Another Education Body suggested that training plans must include links between support networks and mental health and illness.

A Local Authority stated that whilst it is incontrovertible that training is required, workforce planning around training is required overall, with prioritisation of the overall training agenda for staff groups. All additional training requirements need to be quantified in terms of their impact and priority on services. Accordingly, timescales for targets or milestones for each specific individual training requirement in various policy documents should be assured of their authors as being realistic and achievable in terms of resource and other priorities. This point also applied to supporting change section and training and development.

Robust regional commissioning arrangements to be established for dedicated adolescent inpatient provision, including planning, in line with Psychiatric Inpatient Services for Children and Young People: A Way Forward

No comments were submitted regarding this particular action.

Appropriate transition arrangements to be agreed between NHS specialist CAMHS and adult mental health services, including arrangements for handling referrals of young people between the ages of 16 and 18 years

One Local Authority stated that the action was very welcomed - in their area the CAMHS teams do not accept referrals for young people over the age of 16. Adult mental health and psychology services seem to have long waiting lists or do not prioritise emotional difficulties and the proposed expansion of services should go some way in addressing this.

Another Local Authority also welcomed the action, adding that agreement is required between agencies on dealing with transition arrangements for those between the ages of 16 - 18. One other Local Authority suggested that services are extremely limited for adolescents aged 15+ and this needs to be addressed. Additionally, that psychiatric bed provision is very low and when it is available it tends to be geographically remote from community and family, thus increasing the isolation of young people. At times there are no identifiable services and children have to be pigeon holed into the next best thing. There is no mention of children with additional problems and links with mental health services.

An NHS Service Provider supported the need for clarity and consistency in specialist CAMHS in relation to referral ages in young people up to the age of 18.

Clear local leadership to be established, to support NHS specialist CAMHS in adopting the different working patterns required for implementation of the Framework for Promotion Prevention and Care

A Local Authority identified the need to monitor the role of social workers within the CAMHS team, the referrals made to relevant voluntary organisations and the waiting times before receiving a service. There is also a need to ensure good and consistent practice across teams. Another Local Authority stated the role of primary mental health workers working at locality as being key.

A Voluntary/ Charity Body suggested that all NHS Boards and their partners should develop an integrated action plan for implementation of the Framework for Promotion Prevention and Care, with agreed milestones and priorities, including action to ensure the involvement of children and young people.

A Voluntary/ Charity Body indicated that dedicated units should be local to support both young people and their family and at the same time support family and friendship links. This would also ensure that discharge to the local CAMHS teams is effective. Current levels of support could result in long waiting times for specialist assessment and specialist therapy and it would be important to recognise the importance of this on a young person's mental wellbeing.

Other general comments on mental health services for children and young people actions

Additional general comments made included:

• The suggestion of a wider remit in mental health related services for children and young people at risk, encompassing: learning difficulties, challenging behaviour, self harmers, eating disorders and those with disabilities;
• Adequate resources need to be allocated towards prevention and provision of support for vulnerable children and young people rather than focusing just on recovery. Intervention needs to happen earlier;
• There needs to be adequate resources/ funding made available for the CAMHS framework in order to achieve the targets set out;
• More research is needed to establish why children and young people are increasingly at risk from mental health problems;
• Timescales are seen as ambitious given the targets that need to be achieved.

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