National Assembly for Wales

Children, Young People and Education Committee

CAM 24

Inquiry into Child and Adolescent Mental Health Services (CAMHS)

Evidence from : Cardiff and Vale University Health Board

This response is for the Children, Young People and Education committee who are undertaking an enquiry into Child and Adolescent Mental Health Services (CAMHS) and will address each item of interest to the committee.

CAMHS services for the population of Cardiff and Vale are delivered through the CAMHS provider network hosted by Cwm Taf Health Board

1.0 The availability of early intervention systems for children and young people

Specialist CAMHS provide a very limited early intervention service, with the main focus of resources based on providing secondary specialist CAMHS services for children and young people with a diagnosis of mental illness or disorder.

This means that there are a number of areas where children and young people need support for emotional or mental health issues, but where there is not a mental ill health diagnosis, they are unable to access support easily and in a timely fashion.  This is certainly true where children may have suffered adverse early life circumstances and are exhibiting difficult behaviours.  This includes children Looked After by a local authority or those beginning to exhibit significant antisocial or self-harming behaviour.

The current arrangement is that the CAMHS provider network, hosted by Cwm Taf, provides a total of four primary mental health workers for the Cardiff and Vale population who provide support to the wider children and young people’s workforce including: teachers, school counsellors, third sector providers, school nurses and GP’s.  They provide training, advice, signposting and a route of access to specialist services, and are considered by partner agencies to deliver a valuable service through a multiagency model.  However, given the number of workers to provide this service to the Cardiff and Vale population their input is limited.

Part 1 of the Mental Health Measure focuses on providing support through GP’s and primary care.  Whilst this is an important consideration, it is a different approach and model from the one normally seen within children’s services, where most of the requests for early intervention for children with emotional or mental health issues come from Local Authority social services or education partners.

The Cardiff and Vale Health Board has allocated an additional worker for children and young people as part of the implementation of the measure and is currently working through a process to establish how, within limited resources, it can ensure that the requirements of the measure are met to improve support for GP’s, without the risk of reducing the capacity of the valuable multiagency children’s model.

For the Cardiff and Vale of Glamorgan area there is a multiagency group who are focusing on improving early intervention.  It is recognised that there are a number of services providing input to these children and young people, but these are not as joined up as we would like to see. There are services provided through education, such as school counselling, which is a positive step forwards and there are 3^rd sector providers who provide services through Families First in Cardiff.  Improving the emotional and mental health of these children and young people is not purely a health issue and all agencies have a role to play; the key is to ensure linkages and map the support available, which is why the primary mental health workers provide such a valued model.  Early intervention services need to be offered in ways which children and young people can and will choose to access them.

2.0 Access to community specialist CAMHS at tier 2 and above for children and adolescents with mental health problems, including access to psychological therapies

The definition of what constitutes specialist CAMHS at tier 2 and above has been defined by the Mental Health Measure as those with complex needs requiring specialist services. Referrals to services are from GP’s, paediatricians and partner agencies, but there are a number of issues which are of concern to clinicians within the University Health Board.

There have been concerns about the access criteria and about the limited range of provision delivered by specialist CAMHS.  Whilst the local service is delivered by a multidisciplinary team, it operates predominantly as a medical model with strict referral criteria.  This means that if there is no diagnosis of mental disorder following assessment the child or young person is discharged.  In addition, the network operates a purely clinic-based model and if young people do not attend they are discharged.

The CAMHS service operates on a 5 day, 9-5 model, again because of available staffing. This means any urgent issues out-of-hours have to be managed by admission to an emergency unit.

Access to services for children and young people who have a learning disability, challenging behaviour and mental health problems is limited, but the local multidisciplinary team does work closely with the Tier 3 CAMHS specialist to provide a multidisciplinary model.

Access to Psychological therapies in CAMHS is extremely limited and does not comply with NICE guidelines for common conditions.  The network provider does employ a limited number of Psychology professionals but access is following assessment and if no diagnosis of mental disorder is present, psychological support is not available.  Therefore a child or young person requiring therapeutic intervention, without associated diagnosis, has no access to therapeutic support.  A limited number of other staff, including nurses, have had training in psychological approaches.  In the past, social workers funded as part of the CAMHS service in Cardiff and Vale delivered Family Therapy, however the funding for these posts is no longer provided to the network by the Local Authorities.

If specialist CAMHS is seen as a service providing services for children and young people experiencing psychosocial, behavioural and emotional difficulties this is a clear and significant gap in current provision.

3.0 The extent to which CAMHS are imbedded within broader health and social care services

The Welsh Government Strategy – Together for Mental Health – is an inclusive strategy that recognises that the provision of Mental Health Services is a shared responsibility.  There is a multiagency board set up in the University Health Board that should enable closer working between the UHB and social and other partner agencies.  There is a Children and Young People sub-group of the all-age Together for Mental Health Partnership Board. This sub-group also reports to Cardiff Partnership Board and the Vale of Glamorgan Children and Young People’s Board.

Because CAMHS is provided to the Cardiff and Vale population, by another health board, the provider is less integrated and imbedded in local planning arrangements and there have been challenges developing effective shared operational arrangements, but regular liaison meetings have been put into place.

There has been a tendency to use the term CAMHS when referring to all emotional and mental health issues, which has resulted to some extent in it being seen as a purely health service problem.

The UHB is currently working with partners on the commissioning of local CAMHS services to ensure that these services are seen as a shared local agenda.

4.0 Whether CAHMS is given sufficient priority within broader mental health and social care services, including the allocation of resources to CAMHS

Needs assessments indicate that the number of children and young people with emotional and mental health issues are growing and Welsh Government has responded to this with a number of initiatives aimed at improving support, including extending CAMHS to the age of 18 and ensuring access for children with Learning Disabilities.

Extending specialist CAMHS to cover all those up to 18 years of age was supported by some additional funding, but the increase in demand for CAMHS from this age group was under-estimated locally and has a significant impact on the workload of the service.

There has been a tendency to use the term CAMHS when referring to all emotional and mental health and therefore provision of an adequate service has been seen as a health service resource issue.  There has been local disinvestment from social services to the CAMHS network over the past few years and the difficulties of getting the network to engage with local partnership arrangements means that potential funding from partnership sources has not been utilised.

Within the Together for Mental Health all-age approach there is a danger that the different multiagency arrangements and models that exist within children’s services are not recognised or given equal consideration, because of the relative size of the children and adult populations. An example of this is the expectation that Part 1 of the Measure is delivered through primary care and GP referral. Whilst equal access for all ages to Mental Health services should be expected, there should be a requirement to consider the specific needs of children in designing services.

As part of the work the UHB is doing on commissioning CAMHS services, we have worked with our provider network and benchmarked against both NHS CAMHS services in England and the recently released Royal College of Psychiatrists document ‘Building and Sustaining Specialist CAHMS’ and despite recent investment in Welsh services this compares negatively with English services

5.0 Whether there is significant regional variation in access to CAMHS across Wales

There are regional variations because historically the funding arrangements for CAMHS are different throughout Wales and have formed a complicated picture which has become evident as the UHB has commenced its commissioning work.  Some funding was directed through the CAMHS planning network to cover more than one health board, whilst other services have been funded through local funding arrangements.

For Primary Mental Health Workers, the network provider has the same referral routes in place, but the number of workers in each health board area served differs.  The variation is not proportional to the population sizes, so is a variation in the level of service available.

There are Community Intensive Therapy Teams in operation in the Cwm Taf Network area, but these are not in place across all of Wales and do not provide a crisis service.  This situation impacts on Tier 4 inpatient provision.

For neurodevelopmental disorders, in Cardiff & Vale, work is underway on improving shared pathway development, but this model is not the same across all areas served by the provider network.

6.0 The effectiveness of the arrangements for children and young people with mental health problems who need emergency services

Emergency support and crisis provision is poor, particularly outside of 0800-1700 Monday to Friday.  The local CAMHS team should respond to emergencies within office hours and out–of-hours there is an on-call rota that is accessible through Health Services out-of-hours, via the emergency unit.

Timely access to inpatient CAMHS beds when required and to specialist services is problematic. The result is that children and young people are admitted to local emergency units where they may experience delays in assessment and treatment.

Children and young people admitted to acute hospital beds, through the emergency unit, present a specific challenge. They may, after assessment, be deemed not to require a psychiatric admission. Presentation is frequently suicidal thoughts or self harm and once any immediate medical issues are addressed, often a place of safety is required whilst community support is arranged.  Nursing these frequently distressed and agitated young people on general paediatric or adult wards is unsatisfactory for both the young person and other patients. Early intervention and discharge with an appropriate multiagency risk management plan is required

Ensuring specialist CAMHS provision includes intensive intervention in the community and an availability of specialist CAMHS staff in emergency situations would be a significant advance. Intensive crisis intervention services in the community should prevent many emergency admissions.

There are only 14 tertiary CAMHS beds available in South Wales and there is no specialist provision for children and young people who present in a crisis needing a secondary level bed (i.e. they don’t need a specialist inpatient bed).

7.0 The extent to which the current provision of CAMHS is promoting safeguarding, children’s rights, and the engagement of children and young people

The network CAMHS provider has an expectation that all of its clinical staff are trained and updated in all safeguarding procedures and policies.  In addition to this there are Senior Nurses in each area and a Head of Nursing to advise on safeguarding. CAMHS are part of the Cardiff and Vale Safeguarding steering group and link in with local safeguarding leads.

The CAMHS provider network provides access to Advocacy services for children and young people receiving inpatient or community care if required.

Engagement and participation in services is, for the most part, limited to those who have accessed a service commenting upon the service they have received.  Naturally this providing a picture which only reflects the experiences and opinions of those who have been able to access CAMHS.  Planning of services does not currently involve the engagement of children and young people, but the Children and Young People’s subgroup of the Together for Mental Health Partnership board will focus on this as part of its agenda.

8.0 Any other key issues

A lack of specialist inpatient services in Wales can result in individuals having to receive care in England.  For children and young people the aim should be for services to be provided as close to home as possible.  Where children require support from CAMHS as part of a continuing healthcare package or require therapeutic intervention in a placement, CAMHS need to be part of the Cardiff and Vale Health Boards planning and scrutiny processes to inform care packages

Services for vulnerable children in the Looked After system who require early intervention and therapeutic support, but who do not have a clear diagnosis of mental illness or disorder, are not generally available.  Local Authorities and Health Boards have to make individual support arrangements which may be by private psychologists directed by the courts or through a therapeutic residential placement.  This is a significant gap in CAMHS services.

One of the major issues that faced by CAMHS is that when the age range was increased to the 18^th birthday there was limited funding provided to CAMHS services to reflect the transfer of provision from adult services.  This change in the age range has led to an increase in the presentation of young people in crisis and with serious mental illness.

There have been concerns raised about the Mental Health Measure requirements, in particular that Part One of the Measure conflicts with the previous Welsh Government targets and model for CAMHS Primary Mental Health workers.  There is a risk that this multiagency model will be lost due to the requirement to meet a specified Tier 1 target that better reflects an adult orientated service.

In South Wales there are currently 14 beds commissioned for a general inpatient unit. In addition to this there are no commissioned beds in Wales for learning disability or forensic secure placements.  This means that admissions, when necessary, are in England.

Yours sincerely

Dr. Sharon Hopkins

Executive Director of Public Health