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9. Developing High Quality Multi-disciplinary CAMHS Teams

Developing Tier 3 Services

9.1 A critical mass of staffing is required for services to be safe, timely and effective and able to respond to a wide range of demands which include the provision of: specialist and multi-disciplinary assessment and treatment services; teaching, specialist consultation and liaison services; research and audit; and support, training, consultation and face-to-face work within primary care settings. The precise level of staffing will vary according to indices of deprivation, whether the service is in a rural or urban setting, the number of local partnerships required and teaching responsibilities. As services take on the new responsibilities determined by this National Service Framework, additional staffing will be required locally. Where services have good core resources, they are also able to offer a range of specialist and community out-reach services; this arises from the availability of a critical mass of staffing.

9.2 Estimating the numbers of staff required to populate viable multidisciplinary teams and services at Tier 3, that can meet all the demands and provide a sustainable service, is not straightforward. Much depends upon the local demography and the range and types of service needed and offered. Nonetheless guidance has frequently been requested. An analysis of a number of attempts to estimate staffing need has suggested the following: a generic specialist multidisciplinary 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 total population, and a non-teaching service, a minimum of 15 WTEs. Care should be taken to ensure that the number of new cases and overall caseload of each professional is compatible with the complexity of care provided and the specific interventions employed.

9.3 It should be noted that these figures do not reflect demographic variations and areas with high levels of deprivation will need higher staffing levels. While the figures do allow for consultation to other agencies, they do not allow for dedicated staff time from Tier 3 to services such as Sure Start, looked after children teams, special educational needs (SEN) provision, BESTs, youth offending teams etc. Nor would they necessarily be sufficient to provide a team dedicated to specific conditions or specialist services like a day unit. Specific services such as these are increasingly required to meet the expectations now placed on a modern CAMHS.

9.4 Unrealistically high levels of new case assessment in an under-resourced service not only preclude effective work, but may create an unsafe service through insufficient intervention, or a lack of effective monitoring. Excessive caseloads can also squeeze essential workforce activities such as teaching, training and consultation.

9.5 People with the necessary skills and competencies to deliver a comprehensive CAMHS include child psychiatrists, clinical child psychologists, CAMHS trained nurses, occupational therapists, social workers, child and adolescent mental health workers, child psychotherapists, family therapists, specialist teachers, a range of creative therapists and other allied health professionals. Community paediatricians also make a contribution to the service. Many services have not been able to recruit all members of a multi-disciplinary team, which limits their capacity to provide a comprehensive service.

9.6 A variety of therapeutic skills are needed, including behavioural, cognitive, interpersonal/psychodynamic, pharmacological and systemic approaches. These skills are not necessarily all vested in particular disciplines so that a combination of a skills-based and professional-based approach to team development is appropriate.

The commissioning process ensures that services are planned and developed on the basis of needs assessments and the capacity of local services to meet those needs. See section 10

Services are resourced to address variations in staff availability, fluctuations in demand and training and the supervision needs of staff.

Cmmissioners and services ensure that professional and team isolation is avoided. Services ensure that the requirement for a balance of direct and indirect work is reflected in the staffing levels and skills of the team and in individual workloads.

Services offer a comprehensive assessment and treatment service based on a skill mix drawn from professionals from the range of disciplines and therapeutic backgrounds.

Highly Specialised Services (Tier 4 Services)

9.7 The prevalence of severe mental health disorder in children and young people is significant though relatively rare. It includes severe eating disorders, psychoses and major depression, with incidence increasing during adolescence.

9.8 Tier 4 CAMHS refers to the highly specialised provision that may be required by these children and young people. The different range and prevalence of serious disorders in childhood compared with adolescence means that services for these two broad age groups have to cater for a different range of needs, which need to be reflected in the specific skills of the staff working with them. The Department of Health has defined highly specialised services for the minority of children and young people who may need them. The needs of the young people and their families may be met by these services in a variety of ways through intensive outpatient services, assertive outreach, inpatient psychiatric provision, residential and secure provision or other highly specialised assessment consultation and intervention services. Amongst the highly specialist services, inpatient psychiatric units for both children and adolescents, but separately provided to ensure that the developmental needs of different age ranges are met, are essential resources, representing 'the intensive care of child mental health'.

9.9 Due to the insufficient numbers of adolescent beds, some young people are being cared for inappropriately in adult psychiatric beds. In addition, children and young people who are psychotic or who have complex, persistent and severe behaviour disorders and who first present in accident and emergency departments may then be admitted to paediatric wards. A children's ward is not usually the best place for such patients, who may need to be in a children's or adolescent psychiatric unit or other appropriate, jointly agreed, alternative facilities as soon as possible.

9.10 The National Service Framework for Mental Health (13) has addressed the issues involved in providing safe care of sixteen and seventeen year olds, when they are admitted to adult mental health beds:- 'If a bed in an adolescent unit cannot be located for a young person, but admission is essential for the safety and welfare of the user or others, then care may be provided on an adult ward for a short period. As a contingency measure, NHS Trusts should identify wards or settings that would be better suited to meet the needs of young people. A protocol must be agreed between the child and adolescent mental health services and adult services. Protocols should set out procedures that safeguard the patient's safety and dignity.'

9.11 To some extent, whether or not highly specialist services need to be used is dependent upon the availability, quality, range and ability of Tier 2 and 3 services and other social care, education and youth justice services to deliver intensive support and intervention in the community. A further essential ingredient in effective provision for these children and adolescents is therefore the establishment of multi-agency agreements which clarify the level and scope of service provision.

9.12 A network of care is required in each locality for children and young people with severe, challenging and complex problems. This will promote collaborative working between services such as therapeutic fostering, pupil referral units, secure units, adolescent in-patient units and children's homes. Tier 3 and Tier 4 have a role in providing mental health services to secure units (e.g. secure children's homes, secure training centres and young offenders institutions), residential education and residential care, together with other intensive community settings, e.g. specialist fostering.

Multi-agency and specialist commissioning and planning shape Tier 4 services according to need and best practice, enabling the delivery of a volume of services that can encompass the challenges of demand, capacity, diversity and capability.

Emergency care, general and specialist in-patient services (e.g. eating disorders, forensic, medium secure and learning disability) are available for children and young people from each locality. There is a particular need to ensure the availability of beds into which emergencies can be admitted.

There are sufficient numbers of beds matched to need for each locality; i.e. patients who should be admitted on clinical grounds are not refused due to limitation of resources such as bed availability.

Primary Care Trusts and Local Authorities ensure that a network of care is developed in partnership for the provision of Tier 4 services and that written criteria for admission are available and are understood by professionals working with children and young people.

Tier 4 CAMHS work in collaboration with specialist education, social care and youth justice provision to provide a network of services for children and young people with severe, challenging and complex problems.

Primary Care Trusts and Local Authorities ensure that local networks of care are developed between Tier 3 and Tier 4 services to include assertive outreach and day care as well as inpatient and community services.

Specialist CAMHS are involved in the provision of mental health services to secure units, residential education and residential care, together with other intensive community settings (e.g. specialist fostering).

There is close collaboration and liaison with adult mental health services; transfer protocols between CAMHS and general adult psychiatric services are agreed and subject to audit. See Standard 4

When children and young people are unavoidably placed on paediatric or adult psychiatric wards, there is collaboration and joint working between the child health, adult mental health and CAMHS professionals. There is a shared aim to ensure a timely and appropriate placement, if required, in a child or adolescent inpatient unit.

Inpatient units ensure that they conform to a set of quality guidelines such as the Quality Network for Inpatient Care (14)

Discharge and Aftercare

9.13 Discharge planning should receive equal attention to admission planning. Aftercare has a crucial role in the maintenance of treatment gains made during admission. In a minority of cases admission may be a stepping-stone towards longer-term alternative care or residential schooling. The team will need to liaise with a range of local education, social and mental health services.

9.14 The in-patient unit needs to be able to hand over to an appropriately equipped community service. There needs to be a shared understanding of the level of care required on discharge from inpatient services and if the appropriate resources are not available in community services, shared aftercare arrangements should be considered; there may be a continuing role for the in-patient team in the provision of outreach and after-care services.

The Care Programme Approach is used when young people are discharged back to community CAMHS or to appropriate adult services. 

Supporting Staff

9.15 The provision of mental health care for children and young people and their families can be emotionally demanding and stressful, particularly where there are high levels of risk. Support systems to enable staff to practice effectively and safely include the availability of supervision, appraisal, Continuing Professional Development (CPD) and mentoring.

Clear clinical and supervisory arrangements and structures are in place for all staff, to ensure accountable and safe service delivery.

Services ensure that all staff have CPD arrangements in place with professional development plans.

Services consider the value of staff mentoring, particularly for new members of staff.

Evidence-Based Practice

9.16 The requirement to ensure an evidence-based approach to practice presents a particular challenge to professionals working in CAMHS. There is an increasing volume of robust research on the effectiveness of interventions; however, there are a number of limitations to the current research base for CAMHS in the United Kingdom. Children and young people rarely present with single disorders but rather with a range of problems. A large proportion of the available evidence does not reflect the co-morbidity issues which present in day-to-day clinical practice. In addition, services have to rely frequently on either extrapolating research findings from abroad or from adult literature. There are problems inherent in both these approaches. Psychological/behavioural interventions have received relatively little research attention and yet they constitute the main work of CAMHS professionals.

9.17 Lack of evidence of effectiveness does not equate to an intervention being ineffective. It may simply indicate that more research is needed to determine its effectiveness or otherwise. Innovative approaches should be encouraged but should be subject to audit and evaluation.

Services ensure that children and young people receive treatment interventions which are guided by the best available evidence and which take account of their individual needs and circumstances.

9.18 Up until recently, there has been little evidence available to inform the planning and delivery of multi-agency services. An increasing volume of information has now emerged regarding the factors that lead to successful multi-agency service provision in CAMHS15, see Box 3.

Box 3 : Key Elements in a Service that 'Works'

Services need to have:

  • 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, multidisciplinary 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.
Primary Care Trusts and local authorities ensure that multi-agency service planning uses the best available evidence to ensure sustainable and effective services.

Measuring Outcomes

9.19 It is important for the work of the child and adolescent mental services to be appropriately monitored and evaluated and the information used to enhance clinical work, to further service development and to inform users and other stakeholders. However, the processes of evaluation are complex, involving several parties and the tools and methods will need to continue to be developed over the next few years. Services may be supported by joining collaborations such as the CAMHS Outcome Research Consortium (CORC)

9.20 The use of outcome measures will require the availability of basic throughput information on services (for example, number of referrals, new cases and ongoing cases seen, number and types of staff available).

All services routinely audit and evaluate their work. Data collected is made available, in appropriate form, to clinicians, users and commissioners.

Resources, including administrative and clinical time and IT, are available so that routine evaluation of outcome can be carried out in all services.

As a minimum, all services evaluate outcome from the perspective of users (including where possible the referred child or young person themselves as well as key family members or carers) and providers of the service.

Appropriate and Safe Settings

9.21 Many CAMHS community services are poorly housed with insufficient space. Some services are poorly sited with regard to access for families by public transport. Others are also located in proximity to adult services (for example, drug and alcohol services) that may pose risks of harm to the children and young people using the CAMHS. Attention needs to be paid to the built environment for CAMHS including the development of provision in primary care, in schools and in other community settings. Services require appropriate facilities including furniture, telephones, IT and audiovisual equipment, oneway screens and play material.

Primary Care Trusts and local authorities ensure that services are offered in appropriate, safe, child-centred surroundings with the necessary facilities to ensure optimum professional practice.

Programmes for development of facilities take account of the Built Environment report.

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