All CAMHS services are under pressure. They have been affected by chronic underinvestment compared to physical health services; in fact, CAMHS is often described as the ‘Cinderella of the Cinderella service’, receiving less than 1% of NHS funding (Frith, 2016). They are also having to cope with a significant increase in demand. For example, referral rates to Tier 3 CAMHS in England have increased greatly, with the number of cases rising by more than 40% between 2003 and 2009 (JCPMH, 2013).
A recent Europe-wide survey also helps to put UK CAMHS provision in context; showing how the UK lags behind other well-funded countries (Signorini et al, 2017).
The Royal College of Psychiatrists 2013 Report, Building and sustaining specialist CAMHS to improve outcomes for children and young people, sums up the situation well.
“Currently, specialist CAMHS continue to function in an environment where demand frequently exceeds capacity. There are often concerns about access thresholds being set too high, the inability of services to offer an appropriate range of evidence-based interventions, and a ‘clinic-bound’ approach. Teams vary in their eligibility and threshold criteria, professional mix, models of service delivery and commissioning arrangements.”
“As a result of capacity shortage, many struggle to meet waiting-time targets and to implement recommendations set out in clinical guidelines and government directives. The quality and range of specialist CAMHS varies according to the quality of informed commissioning and planning, and the quality and range of services provided by partner agencies. Commissioning and provider arrangements must include agreements to balance demand and capacity to ensure timely assessment and intervention and the use of evidence-based practice.”
NHS CAMH Services in England, Wales and Scotland have all been feeling the strain and have been the subject of recent inquiries and mounting concern about their fitness for purpose. As a result, all three countries have taken the opportunity to review and reassess the way services are commissioned, delivered and evaluated.
In addition, many CAMHS do not have IT systems capable of understanding existing caseloads and matching them against local need. This data would clearly be extremely useful to back up clinicians’ claims of being overworked.
CAMHS in England
In 2014, NHS England published a report on Tier 4 CAMHS. The report found that there is an uneven distribution of services across the country. As a consequence, some children and young people were being admitted to services a long way from home. The report also found evidence of people being admitted inappropriately to CAMHS inpatient services, because of a lack of lower-level community provision.
In the same year, the House of Commons Health Select Committee launched an inquiry into CAMHS. The Committee concluded that “there are serious and deeply ingrained problems with the commissioning and provision of children’s and adolescents’ mental health services”.
As a response, The Children and Young People’s Mental Health and Wellbeing Taskforce was established to look at ways to make access easier and to improve how children and young people’s mental health services are organised, commissioned and provided. The Future in Mind report (DH and NHSE 2015) was one of the outcomes, which laid out core principles and requirements for a system that ‘properly supports the emotional wellbeing and mental health of children and young people.’ This included promoting resilience, prevention and early intervention, improving access to effective support (a system without tiers) and developing the workforce.
In 2016, the Children’s Commissioner published a ‘Lightning Review’ of CAMHS which also highlighted some serious concerns. This included waiting times of up to 200 days, delays in emergency treatment and the number of children and young people not being assessed and treated because they didn’t meet thresholds.
CAMHS in Wales
The National Assembly for Wales Children Young People and Education Committee conducted an inquiry into CAMHS in 2014. A wide range of stakeholders were consulted and the remit of the inquiry included exploring early intervention, access to treatment, regional variations in services and safeguarding issues.
The main inquiry findings were that:
- The level of CAMHS provision is not enough to meet the needs of young people who need a specialist service.
- Difficulties exist for children and young people who do meet the criteria for CAMHS, including waiting times, clinic-based services and the use of prescription medication.
- The absence of services for those children and young people who do not meet the “medical model” criteria for CAMHS means that there is a significant level of unmet need.
There is at present no early intervention in psychosis provision in Wales, which is striking in contrast with England.
CAMHS In Scotland
A 2016 review of mental health services in Scotland (MHF 2016) painted a mixed picture of service improvement and challenges. There were reported improvements in the transitions between CAMHS and adult services, in specialist teams supporting looked after/accommodated young people and those that self-harm and in early Intervention in psychosis teams. However, access to services was reported to be limited, especially outside of major cities. There was also an increasing demand for CAMHS including inpatient psychiatric care. The report made a number of suggestions for improvement, including focusing upon prevention and early intervention, addressing gaps in crisis responses, and stronger connections between in-patient and community teams.