Health Committee Inquiry into Children’s and Adolescent
Mental Health and CAMHS
Written evidence submitted by the UK Council for Psychotherapy
March 2014
1. Executive summary

Child and Adolescent Mental Health Services (CAMHS) do vital work,
which should be celebrated. Overall, the services are well-designed, the
people who work within them are dedicated and highly professional, and
recent initiatives, such as Children and Young People’s IAPT, show a
seriousness of intent on behalf of national leaders to improve child and
adolescent mental health.

Funding cuts to CAMHS are putting the service under severe strain. Even
in extraordinarily difficult financial times, such services should not be cut. If
the national commitment to parity of esteem for mental health is to mean
something, then the mental health and wellbeing of our children and young
people must be a priority, not an easy target for budget cuts.

Our members have raised some specific concerns about the operation of
CAMHS policies at a local level, particularly around the issue of parental
consent and about methods of referral into CAMHS. These examples
highlight the need for consideration about whether a set of national
minimum standards should be introduced for CAMH services.
2. About UKCP
The UK Council for Psychotherapy (UKCP) is the leading professional body for the
education, training and regulation of psychotherapists and psychotherapeutic
counsellors. UKCP’s register of over 7,800 individual therapists is accredited by the
Professional Standards Authority.
As part of its commitment to work for public benefit, UKCP strives to improve access
to psychological therapies, to support and disseminate research, to improve
standards and to respond effectively to complaints against its members.
UKCP holds a national register of psychotherapists and psychotherapeutic
counsellors, listing those practitioner members who meet exacting standards and
training requirements. It also holds a specialist register for psychotherapists working
with children and young people.
UKCP child psychotherapists and family and systemic therapists work across Tiers 2
– 4 in CAMH services, as well as in schools and private practice, referring to CAMHS
where appropriate.
To assist the committee in its inquiry, UKCP has sought the reflections of these
professionals about the operation of CAMHS in England. Consequently, the points
here are based on the experiences of a selection of professionals who work in this
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field. It does not claim to be systematic evaluation of the national picture for CAMH
services.
3. The current state of CAMH services
3.1. CAMHS provides an incredibly important service to children and adolescents
and those who support and care for them. In many areas there are excellent
services, however we are aware that this provision is not consistent, and, in
some areas, young people have to wait too long to access support.
3.2. We are very concerned by evidence of funding cuts to CAMH services
revealed by the Young Minds report in 2013. This showed that approximately
two thirds of local authorities in England had reduced their CAMHS budget
since 2010. These cuts come despite the fact that the contribution to local
authority budgets from the Department of Health for ongoing social support
services has been increasing in real terms over the same period.
Our members who work within CAMHS report the following:
3.3. CAMHS is increasingly acquiring a crisis culture with children and young
people waiting months to be seen, and meanwhile, engaging in riskier
behaviour. Sometimes the clients escalate to the top of the waiting list as a
consequence of their behaviour or even become an emergency admission.
3.4. With Tier 1 and Tier 2 cases not seen at CAMHS, but outsourced to the
community, CAMHS staff are left handling more severe caseloads of clients
only. This has led to greater stresses for CAMHS staff who are managing
higher levels of risk overall and often facing life and death situations on a
daily basis.
3.5. Budget cuts have led to a smaller number of sessions being offered to many
clients and mental health issues are not able to be fully or partially resolved
but merely patched up until the next crisis. One member reported that they
have supervisees working in CAMHS. They are given 4 sessions for “mild
and emerging cases”. In their view, four sessions constitutes an assessment,
not therapeutic work. Where it transpires that the issues are more serious,
there seems to be limited capacity to refer to a higher tier service for more
intensive therapy. Their concern was that in cases like this the child, who
may already have suffered a traumatic situation, faces being passed from
professional to professional to get help.
3.6. We welcome the introduction of the Children’s and Young People’s
Improving Access to Psychological Therapies (CYP-IAPT) as a way of
improving the quality and accessibility of CAMH services. See below.
4. Children’s and Young People’s IAPT
4.1. CYP-IAPT has been backed with £54 million of government funding up to
2015. The increased investment in training and the improvements in client
participation are very welcome. Good supervision and professional
leadership is essential, and CYP IAPT’s focus on this area has been
welcome also.
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4.2. Members of UKCP’s College of Family, Couple and Systemic Therapy have
played a leading role in developing the systemic training pathway for CYP
IAPT. We hope that this post qualification training in family therapy, systemic
practice and systemic supervision will be extended to the workforce across
all services in the country. Strengthening the focus on the family helps
mobilise family networks to greater support the child, reduce unhelpful family
responses to difficulties and limits the potential for family breakdown,
suffering and conflict, including the risk of harm to other family members,
especially other children.
4.3. Despite the many successes of CYP-IAPT, we need to be aware of the risks
of a one-size-fits-all approach to psychological therapies. The introduction of
CYP-IAPT into CAMHS has narrowed the range of therapies available to
support young people. Many children and young people benefit from, and
indeed require, a less cognitive, less verbally-based approach. The necessity
for a diversity of approaches needs to be kept in mind as the programme is
developed.
5. Multiagency working
5.1. The enormous advantage CAMHS offers is a coordinated multidisciplinary
approach. A child or young person potentially has access to medical
interventions from a psychiatrist, individual therapy at CAMHS, help in more
practical areas of life from support workers visiting at home, family therapy
where relevant and, where the family are willing to engage and support, 24/7
help through crisis and out of hours teams.
5.2. The benefits of this also extend to the ability of CAMHS to liaise with other
agencies such as their school and social care services and thereby extend
the safety of the ‘container’ around the child or young person.
5.3. However, we have also heard evidence from members where CAMHS has
accepted referrals from schools, but not made any further contact to liaise
about the child’s circumstances. For practitioners working with young people
in schools it can be difficult to establish whether a young person has
attended the CAMHS appointments and is still being supported by the
service. This lack of contact prevents effective sharing of information.
Without a named CAMHS contact, it can be difficult to set up an effective link
from the school end. It is important to know if the case has been taken for
family therapy, in order to ensure that the child is not seeing two different
therapists at the same time.
5.4. It is important for there to be better connections between physical and mental
health services, such as CAMHS. The connections between good physical
and mental health are well-established, and we need to see closer
multidisciplinary working in the years ahead.
6. Issues of consent
6.1. Our members tell us that some CAMH services will not accept referrals for
children without parental consent. While the involvement of family and carers
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is usually best for the child, and is essential in family and systemic work, very
occasionally parents or carers can withhold consent for their child receiving
help.
6.2. This is especially difficult when there are concerns that the child or young
person is at risk of abuse from parents, or, for personal, family or cultural
reasons, the family are against the child receiving the psychological support
they need. In these incidences, the parents may have an interest in hiding
what is going on, denying that there is a problem and refusing to give
consent. This is problematic because the child, who can be in crisis, is
denied support.
6.3. A blanket requirement for parental consent is inconsistent with Department of
Health guidelines on consent for medical treatment. These guidelines refer to
the notion of ‘Gillick competence’ whereby consent can be given by a child if
it is considered that they have sufficient understanding and intelligence to
enable them to understand fully what is involved in a proposed intervention.
6.4. Further, the guidelines on consent clearly state that, “Where there is doubt
about whether a parent is acting in the interest of the child or young person,
then the healthcare practitioner would be unwise to rely on the parent’s
consent”. We are very concerned to hear of examples where CAMHS are
refusing to take on cases where such doubt clearly exists.
6.5. It is relevant to note that in sexual health the privacy and confidentiality of
under-16s accessing services is well-established. It could be argued that this
is another example of the lack of parity of esteem between physical and
mental health, which needs to be addressed.
Policy recommendation
 Gather evidence on CAMH services about the requirement for parental
consent in cases where the child is deemed at risk of suicide, or it is
considered that there may be an abusive relationship with the parent. On
the basis of that evidence, consider steps to develop national guidelines,
ensuring children under 16 can access psychological support through
CAMHS, if they consent to it, without the need for parental consent. This
would bring child and adolescent mental health services in line with sexual
health services where privacy and confidentiality for under-16s is
protected.
7. Accessing CAMH services
7.1. Our members reported that some CAMH services refuse to accept referrals
from schools and insist on referral via a GP. While this may help with the
management of caseload for overburdened CAMH services, it is an example
of the lack of a joined up approach to support for young people. This is
especially problematic in urgent cases where there are risks of self-harm and
suicide.
7.2. This holds true, even in schools employing qualified mental health
practitioners, such as child psychotherapists. The requirement for GP referral
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lengthens the process, requiring that the GP is willing to liaise with the school
and make the referral and that the young person can have urgent access to
their GP. It also cuts the professionals who work in schools out from the
process of managing that young person’s situation.
7.3. This approach appears inconsistent with NICE guidelines on the
management of mental health problems in children. The 2005 guidelines
emphasise the importance of a collaborative approach from the different
agencies involved in supporting children and young people. As an example,
its guidelines state, “If children and young people who have previously
recovered from moderate or severe depression begin to show signs of a
recurrence of depression, healthcare professionals in primary care, schools
or other relevant community settings should refer them to CAMHS tier 2 or 3
for rapid assessment.” This demonstrates that, at the very least in urgent
cases, CAMHS has a responsibility to take the referral from sources beyond
simply the GP.
Policy recommendation
 Gather evidence from CAMH services about how widespread the practice
of taking referrals only from GPs is. On the basis of that evidence, consider
steps to develop national guidelines, setting out the need for CAMH
services to take urgent referrals from a range of community settings,
including schools.
8. Transitioning to adult services
8.1. Legitimate concerns have been raised about the transition from CAMHS to
Adult Mental Health services (AMHS) at the age of 18. This concern has
been articulated by the current Minister of State for Care and Support,
Norman Lamb MP.
8.2. The present arrangements do not work in the best interests of the young
person. They may have been seeing someone in CAMHS for a while (for
example if they have been referred for an eating disorder) and then at age 18
they are suddenly required to transfer to a different professional in the
Community Mental Health Team. This can be during Year 13, at a very
stressful time when they have important exams approaching, and could be in
the midst of university applications. Young people need to be ‘held’ by
someone they know, rather than experiencing a broken relationship and the
requirement to form new links.
8.3. A 2008 study of young people’s experience of transitions in mental health
services found only 4% of young people reported a good transition, with
many disappearing from services. A national review of CAMH services in
2008 called for national action to improve the quality of transitions for young
people. It is time this issue was revisited as it remains a pressing problem.
8.4. It is worthy of note that there has been a recognition in looked-after child
services that there should not be a sudden cut-off at age 18, because they
are deemed an adult from one day to the next. Instead, the government has
amended the Children’s and Families Bill before parliament to create a
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‘staying put arrangement’ for those up to 21 who wish to remain in foster
care. This is a welcome development and its implications need to be thought
through for other areas of health and social care, particularly mental health.
Policy recommendation
 The point of transition between CAMHS and AMHS needs to be
reconsidered. Instead of 18 years of age, this should aim for a transition
not before 21, and optimally around the age of 25.
9. Commissioning of CAMHS
9.1. With the exception of Tier 4, CAMH services are commissioned at a local
level. A lack of national guidelines is a double-edged sword. Their absence
allows local services flexibility; nevertheless, as demonstrated, they also
permit variations in services which can lead to sometimes confusing and
unhelpful variations in policy.
Policy recommendation
 There is a case for a minimum set of national standards which define what
each CAMH service should provide. This would help address some of the
problems highlighted in this submission on parental consent and referrals
into CAMHS from schools.
10. Further information
Should the Committee want further information on the basis of our submission,
including witnesses to give oral evidence, UKCP would be pleased to provide
support.
Please contact:
Tim Swain
Public Affairs Manager
UKCP
2nd Floor
Edward House
2 Wakley Street
London
EC1V 7LT
Email: policyukcp@ukcp.org.uk
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