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National Service Framework for Children Young People and Maternity Services: The Mental Health and Psychological Well-being of Children and Young People: Standard 9
- 1. Introduction
- 2. Rationale
- 3. Early Years
- 4. Mental Health Promotion and Early Intervention
- 5. Partnerships with Children, Young People and their Families
- 6. Access and Location of Services
- 7. Improving Service Equity
- 8. Partnership Working
- 9. Developing High Quality Multi-disciplinary CAMHS Teams
- 10. Planning and Commissioning Services
- 11. Training and Development
- Appendix 1: A Note on Terminology
- Appendix 2: A Comprehensive CAMHS
- References
- Maternity Services External Working Group Members
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6. Access and Location of Services
'We want a choice where we get help, for instance in school and outside school in a place that isn't medical.' (A user of child and adolescent mental health services)
6.1 Children and young people and their carers want to be able to access services easily. The location should be easy to get to and well-publicised. The views of children, young people and their parents will vary regarding the most appropriate location for receiving help. Services need to be sensitive to these differing views and aim to provide access in a variety of settings, some of which provide the opportunity for self-referral.
6.2 Many children, young people and their families who could benefit from mental health services for assessment and treatment are not accessing services. There are a variety of reasons for this: a lack of trust in statutory services; a wish to solve problems themselves; a lack of recognition and agreement that a problem exists; a fear of being teased and stigmatised; a fear of confidentiality being broken and a belief that nothing can be done. These can all affect the take-up of help.
6.3 It is often the children and young people about whom there is most concern, and who are likely to experience the poorest outcomes, who are most reluctant to seek help. Services therefore need to respond flexibly and creatively in order to be able to meet their needs. The setting in which the first contact is made may make a difference e.g in school which may be seen as less stigmatising for some or, where confidentiality is of particular concern, away from school for a young person who fears being teased.
6.4 For some children and young people and their families, initial access may best be provided in a location of their choice (e.g. school, general practice, or home) with the appropriate facilities. Failure to attend clinic-based appointments should not be seen as a lack of motivation or act as a trigger to close a case but as an indication of the need to review the nature of the service offered.
6.5 It may take some time before a young person is able to take advantage of more specific therapeutic approaches, e.g. cognitive behavioural therapy, so the process of 'engagement' and establishing a trusting therapeutic relationship can be a necessary prelude to a treatment intervention and may take some time. Successful outcomes for children and young people with complex mental health problems rely to a great extent on them being able to understand and 'own' their problems. A flexible approach to the engagement of young people in their own mental health care is often necessary and the relationship with their mental health worker is crucial. See Standard 3
Primary Care Trusts and Local Authorities ensure that information is provided in each locality which explains how to seek advice and gain access to specialist services as necessary. Services are offered as near to home as possible and in a number of settings to take account of the different needs and choices of children, young people and their parents or carers. They should include locations such as schools, homes and family centres, which may be perceived as less stigmatising, as well as traditional clinic settings. Primary Care Trusts and Local Authorities address the need to take services closer to children and young people (e.g. by providing school-based and family/healthcentre based services), especially where parental co-operation presents difficulties, and consider the need for self- referral through a number of entry points to CAMHS at Tiers 1 and 2. See Standard 1 and 3 Services need to establish flexible arrangements in order to meet the needs of children, young people and their families who are reluctant to seek help. Services ensure that training and supervision is in place to address strategies for engagement and to ensure the high quality relationship necessary for successful intervention. |
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Access to Specialist CAMHS
6.6 Waiting too long for a service is clearly unhelpful. The parent, child or young person may be less willing to take up a service where the wait has been excessive. Similarly, there is a risk that a condition may deteriorate and become more difficult to treat.
6.7 There is strong evidence that poor attendance rates in CAMHS are most closely associated with longer waiting lists and with whether parents understand and agree with referral.
'I didn't have to wait very long to get a place. I don't think that people should have to wait more than a few weeks because the problems can get worse if they are left. About one month should be the maximum wait.' (A user of child and adolescent mental health services)
Services agree referral criteria that are explicit and are negotiated between commissioners and providers. Initiatives including increasing capacity and/or alternative care pathways (e.g. the involvement of a voluntary agency or other specialist community resource) are in place to address the gaps in service provision. Mechanisms for increasing access take into account treatment needs, and do not compromise the overall quality of services provided. |
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Emergencies and Out of Hours Services
6.8 Children and young people presenting as emergencies or as requiring urgent assessment and intervention include: those who have rapidly developed a serious or life-threatening condition, for example, a young person who is psychotic or suicidal; those whose needs have become urgent as a consequence of the more routine services having been unavailable to them in a timely way; and those about whom adults are urgently seeking reassurance and support. Improving the scope of existing services and designing them to reflect the opinions of children, young people and their families may do much to reduce unpredicted out-of-hours demands.
6.9 Children and young people with urgent mental health needs may present to a range of agencies during out-of-office hours. These include emergency duty social workers, police, general practitioners and other primary health care professionals and community workers. Professionals working in these agencies need to be able to make an initial assessment of the child or young person's needs and be able to make appropriate referral to specialist services if required.
6.10 Specialist advice is required when a child or young person is presenting with acute psychiatric illness. Currently, on-call and 24-hour specialist CAMHS are not able to be provided in many areas. The lack of equity of access to an emergency out-of-hours service from CAMHS needs to be addressed through short term and long term planning. In the short term, a variety of approaches may be taken to ensure adequate cover in these circumstances. These include: arrangements with adult mental health services to provide first on-call; specialist registrars from a rotation to provide specialist CAMHS on-call, across several providers; consultant child and adolescent psychiatrists having collaborative arrangements with neighbouring services; and multi-disciplinary on-call arrangements, with psychiatric back-up.
6.11 In the longer term, an expanded capacity within CAMHS will lead to an improved ability to respond to urgent need. See Standard 6
Primary Care Trusts and Local Authorities ensure that policies and protocols for the management of children and young people with emergency mental health needs are developed in partnership and clarify the level of service provided and the criteria for referral. Arrangements are in place to ensure that 24 hour cover is provided to meet children's urgent needs and a specialist mental health assessment is undertaken within 24 hours or during the next working day where indicated. (This clarifies the distinction between the initial urgent assessment, for which a range of services, including accident and emergency services are responsible, and the specialist mental health assessment, for which CAMHS are responsible). All staff who are likely to be called upon to carry out the initial social and mental health assessment receive specific training |
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Emergency Admission to Tier 4 Services
6.12 A small number of children and young people require emergency admission to in-patient care. When circumstances permit, prior consultation with the referrer around the emergency may allow the admission to take place as a planned event or alternative arrangements to be made. The latter will be dependent on the level of service provision.
Primary Care Trusts and Local Authorities ensure there is local provision of a range of services (i.e. assertive outreach, domiciliary, community and day services) so that children and young people are not inappropriately admitted to in-patient units. Where a child or young person needs to be placed in an in-patient unit, every effort is made to find a place that is close to home, so that contact with the family can be maintained. Services ensure that admission procedures and policies for all in-patient settings are explicit and developed in partnership with relevant agencies. Children and young people are admitted to settings which are appropriate for their age and maturity. See sections 9.7 to 9.12 |
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