Children and Young People's Mental Health: A Framework for Promotion, Prevention and Care: Draft for Consultation : page 10


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Children and Young People's Mental Health: A Framework for Promotion, Prevention and Care

8. SPECIALIST CHILD & ADOLESCENT MENTAL HEALTH SERVICES

Context

8.1 The primary function of specialist child and adolescent mental health services (CAMHS) is to develop and deliver services for those children and young people (and their families and carers) who are experiencing the most serious mental health problems. These services are provided directly by specialist CAMH teams in many cases, particularly to those children and young people whose difficulties are complex and severe. However, as is clear throughout this Framework, they also have a very important role in supporting what the SNAP report called the "mental health capacity" of the wider network of children's services. This Framework has gone into considerable detail to illustrate the steps necessary to develop that capacity. Detailed recommendations about psychiatric inpatient services for children and young people will be published in a separate report of the Child Health Support Group's Inpatient Working Group.

8.2 Practitioners who contribute to specialist CAMHS include: psychiatric nurses, child and adolescent psychiatrists, clinical psychologists, social workers, psychotherapists (including child/analytical, systemic/family, cognitive behavioural), creative therapists (including art, music and drama), play therapists, liaison teachers, speech and language therapists, occupational therapists and dieticians.

Overarching philosophy & culture

8.3 The English National Service Framework⁵¹ has described the key elements of a child and adolescent mental health service that "works". It suggests that services need:

"Strong inter-agency commitment over the medium to long-term, including a steering group or strategy group willing to tackle tricky issues, and a commitment to consulting with and acting on children's and families views;
Links with existing services within CAMHS, including the integration of the service within the CAMHS tiered framework and CAMHS development strategy;
Links with other services and initiatives outside CAMHS e.g. education, the voluntary sector and area-based initiatives;
An ability to attract new sources of funding;
Retention of a stable, multi-disciplinary staff group with opportunities for training and development;
Positive commitment to continued evaluation and audit; and
Balance between providing a direct service to users and influencing the broader network." (Page 36)

8.4 This applies equally in Scotland. Services should also ensure compliance with professional and other guidelines such as those produced by the Royal College of Psychiatrists and the Mental Welfare Commission for Scotland.

Capacity and skill mix

8.5 The SNAP CAMH report discussed the contribution that specialist CAMHS can make across the continuum of mental health promotion, prevention, treatment and care, and this Framework has described this in some detail. The SNAP report also made clear that an enhanced role - with significant developments in liaison, training and consultation activities, as well as the range of direct work with children, young people, parents, and carers - would not be achievable within services resourced as they were in 2002, when the SNAP review was undertaken.

8.6 The numbers and mix of specialist professions within a specialist CAMHS team will largely depend on local needs assessment and the priorities agreed within a local area. Where the configuration of services is informed by local need and developed in light of the particular patterns of strengths and weaknesses in partner services, local commissioners may be well-placed to develop a view about the overall shape of the specialist CAMHS needed. However, there is a risk that in the absence of indicative figures, NHS Boards and their partners will not be well-placed to make reasoned judgements about the scale of service.

8.7 The English National Service Framework⁵²states that:

"An analysis of a number of attempts to estimate staffing need has suggested the following: a generic multi-disciplinary CAMHS at Tier 3 with teaching responsibilities and providing evidence-based interventions for 0-17 year olds would need a minimum of 20 whole time equivalents (WTEs) per 100,000 population, and a non-teaching service, a minimum of 15 WTEs." (Page 28)

8.8 There are current shortages in available workforce which are impacting on service capacity. A CAMH Workforce Group is currently working on a CAMH workforce profile to support planning for future workforce requirements. This is due to be published in the spring of 2005.

SPECIALIST CHILD & ADOLESCENT MENTAL HEALTH SERVICES

SERVICE ELEMENTS	ACTIVITIES	OUTCOMES
Planning and commissioning	Development of a multi-agency strategy for child and adolescent mental health services on the basis of local needs assessment (including the needs of particular groups of children and young people who are at higher risk of mental health difficulty). Use of the multi-agency CAMHS strategy to inform identification of priorities for investment across the care pathway. Multi-agency planning and commissioning which is informed by: the child and adolescent mental health strategy the views of users, carers and providers service use and outcome monitoring risk analysis strategies for workforce development, development of the estate (new and refurbished) and Information Management and Technology national policies and standards Commissioning which ensures sufficient workforce capacity and skill mix within teams for a range of direct and indirect work to be undertaken across mental health promotion, prevention and care. Commissioning which ensures safe and appropriate environments for the provision of CAMHS. Commissioning of psychiatric inpatient services for young people on a regional basis with inter-regional liaison and co-operation, which implements the recommendations made in the Inpatient Working Group report⁵³. Collaboration with the voluntary sector to provide a range of services across the care pathway.	Strategic investment in sustainable services to meet need. Services are planned and resourced to provide a balance of direct and indirect work. The potential impact of local decisions on services in other areas is recognised and addressed. Multi-disciplinary CAMHS teams which have sufficient capacity and skill mix to function safely and effectively. Children and young people are cared for in comfortable and appropriate environments.
Generic teams of mental health practitioners specialising in work with children and young people across the care pathway	Investment in and redesign of specialist CAMHS to enable staff to provide liaison, consultation and training for staff in universal services who are in contact with children and young people (sometimes called Tier 1 work). CAMHS practitioners working to support colleagues in primary care or directly with children and young people and their family (so-called Tier 2 work). Multi-disciplinary teams working with children and young people with more complex needs (sometimes called Tier 3). Provision of supervision, learning and audit for CAMHS practitioners.	Mental health is "mainstreamed" so that support and intervention is delivered as far as possible within the child's usual environments, via universal children's services.
Emergency and out-of-hours mental health arrangements	Multi-agency development of clear, well understood and well publicised arrangements for assessment and management of children and young people presenting with mental health emergencies on a 24-hour basis. Integration of emergency mental health arrangements with standard NHS arrangements for assessing and managing emergency presentations, and implemented in the same way: via primary care, NHS 24 and accident and emergency services, according to the circumstances. Development of locally agreed evidence-based protocols for managing common mental health emergencies - for example, the assessment of deliberate self harm. Establishment of clear and agreed arrangements to ensure that developmentally appropriate care environments are in place for children and young people requiring psychiatric inpatient care (in line with section 23 of the Mental Health (Care & Treatment) (Scotland) Act 2003). Designation of 1 place within each psychiatric inpatient facility for children or young people for emergency admissions.	Children and young people are able to access appropriate assessment, support and treatment quickly when they need it. Streamlined continuing care arrangements for children and young people presenting with common mental health emergencies. Children and young people requiring psychiatric inpatient care are admitted to developmentally appropriate care environments.
Intensive outreach services	Investment in the development of specialist community "intensive outreach" CAMH teams which provide intensive, flexible and rapidly accessible care for children and young people who present with severe mental health difficulties. Development of intensive outreach services in the context of other specialist CAMHS and ensuring particular links with psychiatric inpatient services for children and young people.	Intensive outreach services are available as part of the overall network of services for children and young people with mental health difficulties. Children and young people with severe mental health difficulties are managed in the community wherever possible.
Inpatient psychiatric services	Inter-regional implementation of the recommendations made by the Child Health Support Group Inpatient Working Group⁵⁴.	Children and young people in Scotland requiring psychiatric inpatient care are able to access developmentally appropriate services, provided consistently across Scotland. Psychiatric inpatient care is provided for children and young people on the best available evidence of effectiveness.
Primary mental health work	Provision and promotion of direct contact between specialist CAMHS practitioners and staff working directly with children and young people in universal services, e.g. schools or primary care. This could be achieved through appointment of designated primary mental health workers, school based link workers or generic community CAMH practitioners adopting a particular role⁵⁵. Provision of supervision, training and support for those engaged in primary mental health work, with ongoing review of needs.	Children and young people receive support and care in their usual environments. Staff in universal services receive training, consultation and support in promoting mental health, preventing mental illness and supporting children and young people with mental health difficulties. Streamlined care pathways for children and young people requiring access to specialist CAMHS. Those engaged in primary mental health work are supervised and supported by the CAMHS team.
Early intervention	Investment in and organisation of CAMHS to promote opportunities for early identification and intervention. ("Early" in this respect refers both to early in the lifecycle and early in the problem cycle). CAMHS teams review their criteria for accessing skilled support. CAMHS teams work closely with primary care and adult services to consider and address the impact of an adult's illness on their children. CAMHS teams work closely with primary care and childcare services to identify children and young people at risk of or starting to experience mental health difficulties.	Children and young people at risk of developing mental health difficulties are identified and supported. Children and young people are able to access skilled support before their difficulties become severe.
Liaison with secondary health care	Clear, negotiated and well publicised arrangements made to ensure that CAMH services are accessible to all secondary health care settings where children and young people are to be found, including: Accident and emergency departments Surgical and medical paediatric wards District General Hospitals Hospital services for children and young people with complex physical (especially neurodevelopmental) disorders Planning in the longer term for the establishment of a dedicated CAMHS liaison service. This may be delivered by a generic, multi-disciplinary or single discipline CAMHS team and may require a regional approach. Implementation of The Child in Mind project⁵⁶ in all secondary healthcare settings to promote awareness of mental health amongst paediatric practitioners.	Mental health awareness is promoted amongst paediatric and other secondary health care practitioners. CAMHS staff contribute to work within paediatric and other secondary health care services to identify and address a child or young person's global needs.
Children and young people with complex physical disorders	Development of clear links between CAMHS and paediatric and other medical services catering for children and young people with complex physical (particularly neurodevelopmental) disorders. Planning to ensure that arrangements include preventive activities, early intervention arrangements and the capacity to collaborate in the assessment and treatment of complex neuropsychological and neuropsychiatric disorders.	The mental health needs of children and young people with complex physical disorders are identified and addressed.
Children and young people with learning disability and mental health problems	Arrangements to ensure that children and young people with a learning disability and mental health difficulties are able to access and benefit from mainstream health services wherever possible. Planning for the development of specialist CAMHS which include members who have training both in relation to children and young people's mental health and learning disability, such as has been described by the Royal College of Psychiatrists⁵⁷.	Children and young people with mental health difficulties and a learning disability are able to access appropriate care and treatment. Staff in generic CAMHS teams and wider children's services are able to access training and consultation.
Forensic services	Planning for the development of forensic capacity within local specialist CAMHS, taking into account the work of the new national Forensic Mental Health Services Managed Care Network (MCN)⁵⁸. Work with local youth justice teams to address the mental health needs of children and young people involved in the youth justice system.	Development of forensic mental health services to meet the needs of children and young people in Scotland.
Substance misuse	Provision of CAMHS input to services for children and young people misusing drugs and alcohol. Planning for the development of specialist CAMHS which include members who have training both in relation to children and young people's mental health and substance misuse issues.	The mental health needs of substance misusing children and young people are addressed.
Liaison with services for looked after and accommodated children and young people	Multi-agency planning and commissioning to ensure the development and delivery of appropriate and accessible CAMHS for children and young people in the care of their local authority, including those in residential and secure settings.	The mental health needs of children and young people in local authority care are identified and addressed.
Therapeutic services	Planning to ensure capacity within CAMHS to deliver a full range of high quality therapeutic interventions covering a spectrum from psychosocial interventions and psychotherapeutic therapies to the skilled use of the range of medications of proven effectiveness. Ongoing training for CAMHS staff in therapeutic interventions.	CAMHS are able to offer a range of therapeutic interventions. CAMHS staff are able to offer training and supervision to others developing therapeutic skills.
Staff training and development	Recruitment of and training for new CAMH professionals to ensure skills and knowledge in both working with children and young people and in mental health. Continuing professional development arrangements, with associated training budgets, for all CAMHS staff in areas such as: Learning disability Working with children and young people with additional and specific support needs Supporting universal services in "mainstreaming" mental health Use of psychoactive medication, cognitive behavioural therapy, child psychotherapy, family therapy CAMHS staff provide advice and training for commissioners and managers about the service needs of children and young people across the continuum of mental health promotion, prevention and care. Input to training in mental health as part of ongoing continuing professional development arrangements for professionals such as: Paediatricians with a special interest in child mental health GPs with a special interest in child mental health Childcare staff Education staff	Staff are appropriately skilled and qualified in mental health issues and working with children and young people. Staff in universal services are supported to promote mental health and wellbeing, and to provide direct support for children and young people experiencing mental health problems. Service commissioners and managers are aware of the specific service needs of children and young people.
Clinical effectiveness	Establishment of routine audit and evaluation mechanisms in line with clinical governance requirements. Evaluation of any new developments, whether translating research findings into practice or seeking new forms of service delivery to address previously unmet need. Development and adoption of reliable systems for evaluating outcomes in CAMHS practice⁵⁹. Consultation with service users on their experiences as an integral part of all service evaluation processes. Provision of appropriate administrative and IT support to facilitate evaluation.	Audit and evaluation is a routine element of CAMHS practice. Outcomes are monitored and evaluated to support service planning and delivery. Service planning, commissioning and delivery is informed by accurate data and robust evaluation.
Research and development	Use of this Framework to stimulate research activity, as well as to provide opportunities for implementation of research findings. Provision of appropriate training and supervision for practitioners within NHS specialist CAMHS to engage in research activity.	Academics and practitioners in specialist CAMHS are supported to engage in research activity. Research in specialist CAMHS extends across the full range of issues relevant to a strategy of promotion, prevention and care, including epidemiology, developing effective interventions, and developing innovative methods of capacity building. Service development is informed by research.

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